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A NURSE'S HANDBOOK 

OF 

OBSTETRICS 



A NURSE'S HANDBOOK 

OF 

OBSTETRICS 



BY 



JOSEPH BROWN COOKE, M.D. 

FELLOW OF THE NEW YORK OBSTETRICAL SOCIETY, ETC 



Seventh Edition, Revised and Reset 

BY 

CAROLYN E. GRAY, R.N. 

SUPERINTENDENT OF CITY HOSPITAL SCHOOL OF NURSING, BLACKWELL'S ISLAND, 
NEW YORK CITY 

AND 

MARY ALBERTA BAKER, R.N. 

LATE SUPERINTENDENT OF ST. LUKES' HOSPITAL, JACKSONVILLE, FLA. 



PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



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Copyright, 1903, "by J. B. Lippincott Company 



Copyright, 1905, by J. B. Lippincott Company 



Copyright, 1907, by J. B. Lippincott Company 



Copyright, 1 909, by J. B. Lippincott Company 



Copyright, 191 1, by J. B. Lippincott Company 



Copyright, 1913, by J. B. Lippincott Company 



Copyright, 191 5, by J. B. Lippincott Company 



PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U. S. A. 



(ami -9 1915 

©CI.A416274 



I 







To the Pupils of the 

City Hospital School of Nursing 

for whose use this book was 

especially written, it is most 

cordially dedicated by 

The Author 



PREFACE TO THE SEVENTH EDITION 

¥¥ 

In revising this book for the seventh edition, it was thought 
best to present the subject matter in a somewhat different 
grouping. The text has been considerably changed and much 
new material added upon current nursing subjects, as well as 
fifty new illustrations and a number of colored plates. 

It is hoped this book will still prove to be a guide and stim- 
ulus to all who follow the traditions and highest ideals of the 
nursing profession. Since 1903 its text has been a model which 
has found much favor. The revision was made possible 
through the courtesy of Honorable John A. Kingsbury, Com- 
missioner of Charities, and the co-operation of the officials, 
doctors and nurses of City Hospital, and various maternity 
hospitals in New York City. 

September, 191 5. C. E. Gray, R.N. 

M. A. Baker, R.N. 



CONTENTS 



CHAPTER PAGE 

I. — Introduction 19 

II. — Anatomy 28 

III. — Anatomy (continued) 34 

IV. — Physiology 43 

V. — Physiology (continued) 48 

VI. — The Physiology of Pregnancy 67 

VII. — The Phenomena of Labor 75 

VIII. — The Physiology of the Puerperium 80 

IX. — The Signs and Symptoms of Pregnancy 84 

X. — The Mechanism of Labor 91 

XL — The Management of Pregnancy 102 

XII. — Preparations for Labor 118 

XIII. — Preparations for Labor (continued) 125 

XIV. — The Conduct of Labor 135 

XV. — The Management of the Puerperium 162 

XVI. — Pathology of Pregnancy 183 

XVII. — Operative Delivery 214 

XVIII. — Abortion and Miscarriage 244 

XIX. — Accidents and Emergencies 253 

XX. — Pathology of the Puerperium 274 

XXI. — The Care of the Normal Infant 290 

XXII. — The Ideal Nursery and Layette 299 

XXIII. — The Accidents, Injuries, and Diseases of the New-Born 317 

XXIV. — The Premature and Feeble Infant 348 

XXV. — Infant Feeding 360 

XXVI. — Obstetrical Nursing 393 

XXVII.— Diets 397 

Appendix 401 

Key to Pronunciation 413 

Glossary 415 

Index 453 



LIST OF ILLUSTRATIONS 

FIGURE PAGE 

i . The normal female pelvis '. 28 

2. The pelvic inlet 30 

3. Male and female pelvis 31 

4. Female pelvis deformed by osteomalacia 32 

5. Harris's pelvimeter 32 

6. Measuring the distance between the crests of the ilia 32 

7. Internal pelvimetry . 33 

8. External organs of generation 34 

9. Internal organs of generation 36 

10. The internal organs of generation, seen from above 37 

1 1 . The uterus and its appendages 37 

12. The cavity of the uterus 38 

13. Ovary and tube of a girl twenty-four years old 40 

14. Mammary gland of a woman during lactation 41 

15. Longitudinal section through ovary of a woman twenty-two days 

after the last menstruation 43 

16. Longitudinal section of ovary of a woman on the first day of men- 

struation 44 

17. Human spermatozoa 48 

18. First stages of segmentation of the ovum of a rabbit 49 

19. Uterus with decidua in beginning pregnancy . 51 

20. Normal position of foetus in utero 52 

2 1 . Fetal surface of the placenta 54 

22. Maternal surface of the placenta 54 

23. Human ovum at the end of the first month 55 

24. Outline of human embryo of about four weeks 56 

25. Human foetus at the end of the third month 56 

26. Skeleton of infant at term 57 

27. Fetal skull, side view 59 

28. Diagram of circulation after birth. Adult type 62 

29. Diagram of circulation before birth. Fetal type 63 

30. Striae gravidarum, or Linear albicantes 68 

31. The breasts in pregnancy 71 

32. Abdominal pigmentation 72 

33. Preserving the perineum 78 

34. Preserving the perineum 78 

35. Using the full hand in retarding the progress of the head 78 

36. Emergence of the forehead and face 78 

37. Delivery of the anterior shoulder 78 

13 



i 4 LIST OF ILLUSTRATIONS 

FIGURE PAGE 

38. Expressing the placenta by the method of Cred6 78 

39. Twisting the membrane into the form of a rope to prevent tearing . . 78 

40. Inspecting the placenta 78 

41. Marked pigmentation of breast 87 

42. Size of the uterus at each month of pregnancy 89 

43. Vertex presentation 92 

44. Flexion of head during second stage 94 

45. Extension of the head in anterior presentations of the vertex 95 

46. External rotation 96 

47. Internal rotation and extension 97 

48. Shape of head of child born in face presentation 98 

49. Shape of head of child born in brow presentation 98 

50. Face presentation 98 

5 1 . Breech presentation 99 

52. Prolapse of arm in transverse presentation 99 

53. Usual method of palpating the abdomen 100 

54. Abdominal binder 103 

55. Showing manner of elevating bed 129 

56. Arrangement of sheets for vaginal examination 138 

57. Esmarch outfit for the administration of chloroform 142 

58. Administration of chloroform 143 

59. Administration of ether 147 

60. Square knot 153 

61. Granny knot 154 

62. Delivery of placenta and membranes 155 

63. Delivery of the head in breech cases 156 

64. Arms extended in breech delivery 158 

65. Locked twins 159 

66. Holding the fundus after delivery 162 

67. Abdominal binder 169 

68. Glass catheter - 173 

69. Proper method of inserting catheter 175 

70. Method of withdrawing catheter 175 

71. Proper method of introducing douche-tube 178 

72. Varicosities of the lower extremities 189 

73. Ectopic gestation 207 

74. Placental attachment 209 

75. Internal version 214 

76. Combined or bipolar version 215 

77. "External version" 216 

78. Forceps applied to head of brim 218 

79. Walcher posture 218 

80. Ready for vaginal operation 219 

81 . Sterile pillow cases for covering the limbs 220 



LIST OF ILLUSTRATIONS 15 

FIGURE PAGE 

82. Kitchen table utilized for operating table 221 

83. Elliott's forceps 222 

84. Simpson's forceps 223 

85. Tucker-McLane forceps 223 

86. Tarnier axis- traction forceps 223 

87. Barnes's bags 224 

88. Champetier de Ribes bag 225 

89. Bulb and valve, or " Davidson " syringe 225 

90. Method of inserting bag 226 

91 . Method of inflating bag 227 

92. Pelvic tumor preventing delivery 228 

93. Kelly pad in position under patient 229 

94. Sterile salt solution in flasks 230 

95. Sponge made of cotton and gauze 230 

96. Sponge holder 230 

97. Intestinal pad of folded gauze. 231 

98. Gauze packing 231 

99. Saline infusion 232 

100. Galbiati knife 234 

101. Nurse's proper operating gown 235 

102. Doctor's proper operating gown 235 

103. Naegele's perforator 239 

104. Braun's cranioclast 239 

105. Tarnier's basiotribe 239 

106. Impacted shoulder presentation 240 

107. Braun's key-hook 240 

108. Braun's hook applied . 241 

109. Long, blunt scissors. For decapitation and evisceration 241 

1 10. Bougie for the induction of labor 242 

in. Sims's position 243 

1 12. Author's leg-holder 247 

113. Robb's leg-holder 247 

114. Sims's speculum 248 

115. Schroeder's vaginal retractor 248 

1 16. Bullet-forceps 248 

117. Modified Goodell-Ellinger dilator 248 

118. Uterine sound 249 

119. Placenta-forceps with heart-shaped jaws 249 

120. Curettes 249 

121. Sponge-holder 249 

122. Two-way catheter 250 

123. Concealed hemorrhage 254 

124. Rupture of the uterus 257 



^ LIST OF ILLUSTRATIONS 

Fli;i'Rh PAGE 

1 25. Complete inversion of the uterus 258 

126a. Prolapse of the umbilical cord 260 

1 26b. Knee-chest position 260 

127. Manual extraction of the placenta 263 

128. Murphy saline drip apparatus 269 

129. Aspirating needle 270 

130. Hypodermoclysis 271 

131. Figure-of-eight ligature. For controlling secondary hemorrhage 

from the umbilicus 273 

132. Tray with everything needed for the care of the breasts 279 

133. Massage of the breast 280 

134. Nursing bottles and rubber nipples 282 

135. Author's breast-binder 284 

136. Pattern of author's breast-binder 286 

137. Oiling and dressing the new-born infant 291 

138. Method of dressing the umbilical cord 294 

139. Infant's crib with adjustable sides 300 

140. Practical infant's crib 301 

141. Double wash-basin 302 

142. Paper bags pinned together 302 

143. A. Infant's dressing screen. B. Infant's dressing table 303 

144. Method to secure air for infant in a city apartment 305 

145. Another view of Fig. 144 306 

146. Diaper shaped according to pattern 307 

147. Ideal infant clothing 313 

148. Patterns of infant's clothing 314 

149. Band and shirt fastened with tapes 315 

150. Slapping upon back to induce respiration 318 

151. Snapping the finger upon the soles of the feet to stimulate respi- 

ration 319 

152. Byrd's method of resuscitation. Expiration 321 

153. Byrd's method of resuscitation. Inspiration 322 

154. Artificial respiration. Expiration 324 

155. Artificial respiration. Inspiration 325 

156. Sylvester's method combined with tongue traction 327 

157. Schultze's swinging method. Expiration 328 

158. Schultze's swinging method. Inspiration 330 

159. Removal of mucus with aspirating catheter -. . . 331 

160. Warm bath combined with tongue traction 332 

161. Facial paralysis 333 

162. Caput succedaneum 333 

163. Double cephalhematoma 334 

164. Technic of applying ice compresses to the eye 336 

165. Technic of irrigating eye 338 



LIST OF ILLUSTRATIONS 



17 



FIGURE PAGE 

166. Thumb-forceps 339 

167. Spina bifida of dorsal lumbar region 340 

168. Spina bifida. Spontaneous cure 341 

169. Opisthotonos 344 

170. Electrically heated infant incubator 350 

171. Gas heated infant incubator 352 

172. Tarnier's incubator, interior 353 

173. English breast-pump 356 

174. Feeder for premature infant 357 

175. Infant premature at thirty weeks 358 

176. Soft, flabby breasts 361 

177. Two-ounce vial with nipple 363 

178. Articles required for the preparation of artificial food 383 

179. Nursing bottles 385 

180. Testing size of opening in nipple 386 

181. Steam sterilizer 390 

182. Freeman pasteurizer 390 

183. Operating gown and case 393 

184. Scales and hammock for weighing infant 394 

185. Sponge attached to safety-pin with snaps 405 

186. Delivery bag 408 

187. Nurse's bag 410 

188. Contents of bag 411 



A NURSE'S 

Handbook of Obstetrics 



i 

Introduction 

The art of nursing the obstetrical patient is practised by 
various classes of people. We are very prone to consider only 
the doctor and the trained nurse. Statistics, however, demand 
consideration of other factors. Taking any city or town in 
the United States, we find that a woman about to present her 
most valuable gift to the world, a healthy child, if not provided 
with hospital care away from the family, may be cared for: 

i. By the doctor, in his out-patient and country practice. 

2. The nurse midwife. 

3. The graduate nurse in private, hospital, visiting nurse 
and rural Red Cross work. 

4. Various orders of nursing sisterhoods. 

5. A trained midwife from schools of midwifery abroad. 

6. The midwife trained in American schools of midwifery, 
such as Bellevue. 

7. The correspondence school graduate. 

8. The untrained nurse. 

9. The licensed midwife. 

10. The unlicensed midwife occasionally. 

11. Relatives of the patient. 

12. Neighbors. 

The dominant issue of the present-day teaching is preven- 
tion of waste. All civilization is striving, by every means pos- 
sible, to conserve and add to the vital resources of the nation. 
A few daring bacteriologists have done research work which 

19 



20 A NURSE'S HANDBOOK OF OBSTETRICS. 

has given us perhaps our greatest influence and inspiration to 
this end, in preventive and curative medicine. 

This knowledge is in a large measure rendered ineffective 
by the dense amount of deep ignorance concerning the facts 
of life. 

Tradition, prejudice, and social customs all tend to sur- 
round the practice of obstetrics with conditions which are 
largely responsible for the following figures which are inserted 
as an example of some of the results of the care given at 
childbirth. The figures are by Doctor Haven Emerson, Deputy 
Commissioner of the Department of Health of the City of 
Xew York. 

IN NEW YORK CITY FOR THE YEAR I9I4 

Number of births reported by physicians 87,650 

Number of births reported by midwives 52,997 

Number of infant deaths under ten days reported by physicians. . 3,683 

Number of infant deaths under one year 13,312 

Number of cases of ophthalmia neonatorum reported by physicians 14 

Number of cases of ophthalmia reported by midwives 12 

Number of deaths in 19 14 from puerperal sepsis 1 407 

Number of midwives practising in New York City 1,448 

These figures and facts are not dull, but force the logical 
conclusion that the most essential fact of obstetrics is a knowl- 
edge and a following of a high standard of asepsis. This fact 
cannot be brought before the public too emphatically, too 
clearly, or too often. 

It is the definite duty of every nurse to follow the medical 
profession closely, and by utilizing every opportunity that sym- 
pathy and tact may devise, to teach unceasingly the doctrine of 
prenatal care and the need of the best obstetrical assistance. 

Nature makes lavish efforts to protect the expectant mother 
from infection. This is interfered with by contact infection 

thirty-five per cent, of these deaths were in women who had fceetr- 
att ended by midwives prior to the development of the sepsis, which ended 
in their deaths. It is approximately estimated that between six and seven 
thousand deaths from puerperal sepsis occurred in the United States in 
the same year. 



INTRODUCTION. 21 

from the family, from visitors, from the patient herself, and 
from the nurse or doctor. 

Aside from the natural immunity possessed by healthy tis- 
sues against infection, there is the vaginal secretion, which is 
usually spoken of as being a natural antiseptic. What is meant 
is, that while swarming with bacteria, these bacteria manufac- 
ture lactic acid, and no pus organism can survive in an acid 
medium. 

Normally the changes in the soft parts of the reproductive 
organs during pregnancy and labor are accompanied by an 
increased amount of vaginal secretion. Beyond this there is 
the closed door to infection of the uterus itself, by means of a 
mucous mass or plug, called the operculum. 

At the end of the first stage of labor the membranes rupture, 
the liquor amnii carries with it the vaginal contents and a 
large percentage of the bacteria. 

The vaginal walls enlarge during the actual passage of the 
child; this is followed by the remaining liquor amnii, and, 
finally, by the delivery of the placenta ; so that there is left but 
little chance for bacteria to survive. 

The whole object of asepsis is to prevent infection of the 
uterus from the outside. Obviously this resolves itself into 
a principle of prevention of infection during labor, and the 
practice of rigid asepsis and faultless technic on the part of the 
doctor and nurse. 

Every case of puerperal sepsis, with rare exception, proves 
that infection has been introduced from the outside by septic 
hands, septic instruments, or septic matter from the vulva or va- 
gina carried by douches or instruments into the uterus. The 
septic infection comes from anything not sterile. This is occa- 
sionally unavoidable, owing to complicated instrumental or oper- 
ative delivery, but a pyogenic infection has no more place in ob- 
stetrics than in surgery, and it can be almost as certainly pre- 
vented. 

Septic infection from the hands may be prevented by proper 
cleansing, wearing of gloves, and then by using the hands only 
when imperatively demanded. 



A NURSE'S HANDBOOK OF OBSTETRICS. 

Septic infection from instruments may be prevented by 
proper cleansing and boiling; then proper technic in the treat- 
ments or douching will prevent the carrying of infection from 
the vulva or vagina. 

Whether the infection is mild and results in invalidism, or 
whether it is virulent and causes death, the nurse who is in- 
telligent and conscientious will feel strongly her responsibility. 

POINTS FOR THE OBSTETRICAL NURSE 

Pasteur said : " It is within the power of man to cause all 
parasitic diseases to disappear from the world." Fatal cases 
of puerperal sepsis in a hospital are almost unknown. They 
should be equally rare in the home; and if proper care is 
exercised this will be the case. 

The purpose of this elementary review is to lessen the total 
of 6000 deaths per year in the United States. It is hoped that 
all who read it will consider it seriously, whether they are 
graduates, undergraduates, midwives or lay helpers. 

Bacteria are vegetable organisms. 

Pathogenic bacteria are those organisms which cause morbid 
or diseased changes in human tissues. 

Infection is the communication of disease from one person 
to another. The term is also used to denote the agent by which 
disease is conveyed. 

Septic infection is infection caused by septic organisms. 

Sepsis is infection by bacteria. 

Asepsis means without sepsis ; that is surgical cleanliness or 
freedom from infection. 

Aseptic means in a surgically clean manner. 

Pyogenic relating to pus-forming organisms. 

Sterile means entire absence of living organisms of any 
kind. Sterilization is the process of rendering an object free 
from germs. 

Antiseptic means preventing sepsis or pus formation or 
putrefaction. 

(1) No one should undertake obstetrical nursing who has 



INTRODUCTION. 23 

any pus infection whatever, or who has been recently exposed 
to a communicable disease. In such a case, report the exact 
condition to the obstetrician and act under his orders. Carry 
out thoroughly a system of disinfection. 

(2) Articles for emergency use, packings, dressings, treat- 
ments, etc., should be sterile and in readiness; neglect to 
provide these is criminal. Wisdom lies in the prevention of 
infection and in preparation for emergencies. 

(3) Prepare all essentials for doctor (see list). Prepare 
all essentials for nurse (see list). Prepare all essentials for 
mother (see list). Prepare all essentials for infant (see list). 

(4) Hands must be thoroughly scrubbed under running 
water for five minutes with any good soap and a clean nail 
brush ; use particular care between the fingers and around the 
nails. Cut the nails close and manicure often. Soak in biniodide 
of mercury 1 : 1000, or sponge with alcohol 95 per cent. Wear 
rubber gloves, previously sterilized by washing and boiling for 
five minutes. 

(5) Fingers must never be used where an applicator or 
forceps can be made to serve. These are to be kept in a jar 
filled with 2 per cent, solution of lysol or 95 per cent, alcohol. 

(6) Use sterilized soap. 

(7) Never use grease as a lubricant. It is always dirty, 
and it destroys rubber. Use lysol, 2 per cent., or a sterile emul- 
sion made from soap. , 

(8) Never catheterize a patient unless all possible means 
to avoid it have been tried ; and then only by express order of 
the doctor, and with exact technic. 

(9) A nurse should not renew a vulva pad after removing 
a bed-pan from her patient until she has made her hands sur- 
gically clean. 

( 10) Especial care is essential to prevent infection of vulva, 
bladder, and breasts. 

(11) A cord dressing will not be reinforced or renewed 
until the nurse has surgically clean hands. 

(12) She will never leave a patient's breast exposed, but 
will protect it by a sterile dressing, and use sterile cotton swabs 



24 A NURSE'S HANDBOOK OF OBSTETRICS. 

when cleansing the nipple, at all times treating both breast and 
nipple as open wounds. 

(13) So long as she is with her patient she will keep a 
complete daily record of patient and infant, charting all physi- 
cian's visits and treatments. 

(14) She may use a fountain syringe for enemata, but an 
agate irrigator with cover and separate tubing carefully boiled 
is essential for infusions and for sterile uses. 

(15) She will tactfully instruct her patient not to infect 
herself or infant, and will strive to prevent the baby from 
developing bad habits. Failure to do this is inexcusable. 

(16) She will handle conditions so that the equipment the 
home affords may be utilized to the advantage of the patient, 
and by her resourcefulness and adaptability render the eco- 
nomic drain upon the family income as small as possible, 
without sacrificing a single principle of asepsis. 

(17) The nurse should prove a continuous exponent of 
personal hygiene, in person, uniform, and habits. 

(18) She must never relax in vigilance, duty, judgment, or 
loyalty. 

The feminist movement is strongly pushing forward a de- 
mand from women themselves for better obstetrics, for better 
training and judgment on the part of both doctors and nurses. 
They are less willing to accept inferior service, and demand 
that the best help available be given them. 

Operations are often attempted at home that should in 
justice to the mother and child be performed in hospitals. 
Lack of adequate assistance or equipment and improper sur- 
roundings not infrequently render recovery problematical. The 
patients and families must be taught that this is highly im- 
proper and that the obstetrician must have adequate assistance 
and remuneration. Good judgment, swift decisions, and quick 
action are in demand from the obstetrician. He should have 
assistants and a nurse worthy this need. Only with a large 
intelligence and sympathy, trained in technic, plus experience, 
can a nurse fulfil her opportunity. Private nursing lays greater 
responsibility upon her than does her hospital work. She must 



INTRODUCTION. 25 

have a sufficient knowledge of psychology to follow the mental 
processes of her patient. Thus, the nurse should secure her 
patient's confidence, and persuade her to place herself in the 
care of a physician as soon as possible ; she should help her 
to live a normal life, induce her to eat proper food, take suffi- 
cient exercise, secure enough rest, and happily to await her 
baby's coming. She should ward off dread of suffering by 
being able to promise that a good obstetrician will not let her 
suffer too much actual anguish. She should make real to her 
that the care of her infant begins nine months before it is 
born ; that the baby requires only a few articles of a very special 
kind and that these should be in readiness ; that her own re- 
turn to normal health and comfort, as well as her child's best 
chance for life, lies in her preparing to nurse it, and that all 
the earth does her honor. 

When on the case, dignity, efficiency, cleanliness and quiet 
are most essential. Too many objectionable traits, such as 
gossiping, relating personal details, reciting history of cases, 
disturbing domestic regime, discourtesy, etc., when placed in the 
balance beside skill, are found to outweigh efficiency, and the 
nurse becomes a menace to the well-being of her patient. 

The strength and force of character possessed by a nurse 
will enable her to become a tower of strength to the expectant 
mother, and by proper suggestion and direction of her mind 
the actual realization of her sufferings may be much lessened. 
If the nurse is unintelligent or unobservant of her patient's 
attitude of mind, she may undo all the efforts of the physician 
to encourage and assist. It should be a part of her training, and 
it is her duty, to help her patient mentally as well as physically. 

In a paper read recently before one of the great medical 
societies of New York the gynaecologist was styled " that obstet- 
rical camp-follower," and this characterization may well serve 
as a text for a dissertation on obstetric nursing. 

Practically all women who consult the gynaecologist are mar- 
ried, have borne children, and date their troubles from the birth 
of one or another child, and it is safe to say that the compara- 
tively few unmarried women who seek advice for the relief of 



26 A NURSE'S HANDBOOK OF OBSTETRICS. 

pelvic disorders would be in infinitely worse condition than they 
are if they had passed through the ordeal of pregnancy and 
labor. 

The amount of good for womankind that nurses can accom- 
plish by the dissemination of judicious advice concerning the 
requirements of the pregnant state and by intelligent care of 
parturient and puerperal cases, probably exceeds in many ways 
the best efforts of the physician. Especially among primi- 
gravidae does this hold true, for women who have never borne 
children are often remarkably diffident in regard to their condi- 
tion, and unless the early symptoms of pregnancy are exception- 
ally severe, they will neglect to place themselves under medical 
care until much mischief may have been done. 

When nurses, as a class, will impress upon women who may 
come under their notice the importance, not only to themselves 
but to their infants, of consulting and implicitly following the 
directions of a skilful obstetrician as soon as they have reason 
to suspect that they are pregnant, they will save a large number 
of these patients many visits to the gynaecologist in after years. 

A nurse can, with propriety, volunteer advice -of this kind 
when a physician, taking the same stand, would often be unjustly 
suspected of ulterior motives, and her opportunities for doing 
so are greater than his in the exact proportion in which a woman 
will discuss a delicate subject with another woman more fre- 
quently and more freely than with a man. 

Regarding nursing in the light of a noble profession, closely 
allied to that of medicine, no opportunity for aiding and perma- 
nently benefiting humanity will ever be overlooked, and scientific 
supervision of pregnancy, labor, and the puerperium can do 
more in this respect than all other branches of nursing com- 
bined. 

As the writer has expressed in another place, let the pregnant 
woman be taken in hand at the very beginning of her pregnancy 
and put in condition to withstand the ordeal through which she 
has to pass, much as the athlete is " trained" for months before 
the encounter in which he is to figure. 

It may be stated, as a general rule, that no woman should die 



INTRODUCTION. 27 

or even be seriously invalided as a result of pregnancy if she is 
under proper care from the beginning of gestation, and it rests 
with the nurses of modern times more than with the physicians 
to see that every woman is afforded such care and attention as 
will insure the successful outcome of her case. 

The key-note of success in obstetric practice lies in a thor- 
ough knowledge of the patient's exact condition long before 
labor occurs and in ample preparation for delivery and after 
care, so that the labor may be conducted with every attention to 
aseptic detail and modern surgical method. 

Twentieth century civilization has done much to retard the 
physical development of women in general, and, among those 
who are in a position to afford the services of a graduate nurse, 
very few have sufficiently robust constitutions and normally de- 
veloped pelves and generative organs to make labor and its after 
effects anything but a matter of considerable moment. 

Unless the physician has been afforded an opportunity to 
build up their general health and keep a watchful eye on the 
behavior of their bodily functions, and unless the nurse has 
made careful and judicious preparations for conducting their 
labors in a thoroughly aseptic manner, complications may arise 
at the last moment which may result in permanent invalidism, 
if not in the death, of the mother or child. 

Obstetric nursing presents many unattractive features, for 
after labor there are two patients instead of one to be cared for, 
but it offers so many and so great opportunities for the advance- 
ment of " preventive medicine" that the writer cannot but look 
with considerable disfavor upon that large and constantly in- 
creasing class of hospital nurses who regard maternity cases as 
entirely beneath their dignity and who leave these unfortunate 
patients in the care of unskilled attendants, only to nurse them 
afterwards when they reach the operating-table of the gynae- 
cologist. 



II 

Anatomy 

THE PELVIS 

The pelvis (Fig. i) is that portion of the skeleton which 
lies between the spinal column and the lower extremities. It is 




Fig. i. — The normal female pelvis. (Garrigues.) A, sacrum; i?, coccyx; C, crest of 
the ilium; D, acetabulum; £, spine of the ischium; F, symphysis pubis ; G, spine of the 
pubis ; H, obturator foramen ; /, tuberosity of the ischium ; J, J, J, linea terminalis. 

composed of four bones, — the sacrum and coccyx behind, and 
the innominate bones (ossa innominata) at the sides and in front. 
Each innominate bone (os innominatum) is divided by anato- 
mists into three parts, — the ilium, the ischium, and the pubis. 

The ilium, which is the largest portion of the bone, is broad, 
thin, concave on its inner aspect, and lies above the narrow con- 
stricted portion of the pelvis. Like its fellow of the opposite 
side, it is joined to the sacrum behind, and its upper flaring 
28 



ANATOMY. 29 

border forms the prominence of the hip, or crest of the ilium, 
commonly spoken of as the " hip bone." 

The pubis joins directly in front, in the median line, with 
its opposite fellow, and closes, anteriorly, the cavity of the pelvis. 

The ischium, which is that portion of the innominate bone 
lying beneath the ilium, is not of importance to the obstetric 
nurse, although it is of interest to know that it occasionally pre- 
sents bony projections {exostoses) of sufficient size to obstruct 
the descent of the head during labor. 

The sacrum is a triangular, wedge-shaped bone, consisting 
of five rudimentary vertebrae welded together, and lies at the 
back part of the pelvis, between the ilia (plural of ilium), closing 
in the cavity behind. Its upper surface, or base, is broad and 
flat, and supports the spinal column ("backbone") and with it 
the entire weight of the body. Its apex points downward and 
forward, and to it is attached 

The coccyx, a very small triangular bone, resembling some- 
what in appearance a miniature sacrum and being possibly the 
remains of a prehistoric caudal appendage, or tail. 

Regarded as a whole, the pelvis may be described as a deep, 
bony basin resting on the upper extremities of the two femora 
(plural of femur), or thigh bones, and supporting the spinal 
column, which carries the weight of the trunk, the head, and 
the upper limbs. The flaring surfaces of the ilia make a sort 
of funnel to guide the foetus into this basin, which, having no 
bottom, forms a bony canal through which the child has to pass 
at the time of labor. 

The most constricted portion of the pelvis is called the brim, 
or inlet (Fig. 2), and is, naturally, of the greatest obstetric im- 
portance; for, as a chain is only as strong as its weakest link, 
so is a canal only as broad as its narrowest part, and, except in 
certain cases of deformity, any child that can pass safely through 
the brim can be delivered without any further difficulty. 

The brim of the pelvis is bounded behind by that portion of 
the upper anterior surface of the sacrum, which projects farthest 
forward and is called the "promontory of the sacrum;" on the 
sides by the lower borders of the ilia; and in front by the two 



3o 



A NURSE'S HANDBOOK OF OBSTETRICS. 



pubic bones, which meet in the median line and form the " sym- 
physis pubis." 




Fig. 2. — The pelvic inlet. (Garrigues.) A B, anteroposterior or true conjugate diame- 
ter; CD, left oblique diameter; E F, right oblique diameter; G H, transverse diameter; 
A S, sacrocotyloid distance; IK, crest of the ilium. 

The contour of the inlet is more or less heart-shaped because 
of the jutting forward of the promontory of the sacrum, and the 
most important diameter of the pelvis is the distance between the 
promontory and the symphysis. If this is normal (ten centi- 
metres, or about four and one-quarter inches), it is almost cer- 
tain that the entire pelvis is normal, and that the child can be 
born without any serious difficulty. 

The articulations {joints) of the pelvis, which possess ob- 
stetric importance, are four in number. Two are behind, between 
the sacrum and the ilia on either side, and are termed the sacro- 
iliac synchondroses (plural of synchondrosis) ; one is in front, 
between the two pubic bones, and is called the symphysis pubis; 
and the last, of little consequence, is that between the sacrum 
and coccyx, — the sacro-coccygeal articulation. 



ANATOMY. 



31 



All of these articular surfaces are lined with fibro-cartilage, 
which becomes thickened and softened during pregnancy, and a 
certain definite, though very limited, motion in the joints is 
essential to a normal labor. Even an ankylosis of the sacro- 
coccygeal articulation, preventing the tilting backward of the 
coccyx at the time of delivery, may necessitate the use of for- 
ceps, and, in the operation of symphyseotomy, which consists 
in cutting through the symphysis pubis and so separating the 
pubic bones, no increase in the capacity of the pelvis could be 
secured were it not for a very distinct hinge-like motion at the 
sacro-iliac synchondroses. 

The pelvis is lined with muscular tissue, which provides a 
smooth slippery surface over which the foetus has to pass during 
labor, and its bones are bound together by ligaments, which 
become softened and slightly lengthened as pregnancy advances. 

Comparing the female with the male pelvis (Fig. 3), we 
find that the former is especially adapted to the uses for which 




Fig. 3. — Male and female pelvis. A, male pelvis — narrow, heavy, compact ; B, female 
pelvis — broad, light, capacious. 



it is designed. It is shallow, but very capacious, lighter in struc- 
ture and smoother than the male pelvis, which is deep, conical, 
rougher for muscular attachment, and more compact. 

The entire problem in obstetrics consists in the safe passage 
of the fully developed foetus through the pelvis of the mother. 
Slight pelvic contractions, resulting in tedious or instrumental 



32 



A NURSE'S HANDBOOK OF OBSTETRICS. 



deliveries, are comparatively common, while any such marked de- 
formity as depicted in Fig. 4 would render labor by the natural 




Fig. 4. — Female pelvis deformed by osteomalacia. (Garrigues.) 

passages entirely out of the question. For these reasons the 
pelvis of every pregnant woman should be measured carefully 
at a sufficiently early date to enable the physician to determine 
definitely the proper course to pursue. 




Fig. 5. — Harris's pelvimeter. 



The external pelvic measurements are taken with an instru- 
ment called a pelvimeter (Fig. 5), which acts on the principle 



% 




Fig. 6. — Measuring the distance, iliac crests. 



ANATOMY. 



33 



of a carpenter's or plumber's calipers. The patient lies on her 
side or back, according to the diameters to be measured, with 
the abdomen exposed, as shown in Fig. 6. The internal pelvic 
measurements, for determining the actual diameters of the brim, 
are usually made by inserting two ringers into the vagina and 
up to the promontory of the sacrum and estimating the various 
dimensions in this manner (Fig. 7). 




Fig. 7. — Internal pelvimetry. Measuring the distance between the promontory of the 
sacrum and the lower border of the symphysis pubis. 

The importance of the knowledge gained through the skilful 
performance of external and internal pelvimetry cannot be over- 
estimated, and it should never be neglected in the case of a 
woman pregnant for the first time nor in any case in which the 
patient has suffered previously from difficult or tedious labors. 

In cases of slight contraction the induction of labor two or 
three weeks before term may be all that is necessary, while the 
existence of marked deformity may call for the performance of 
Caesarean section as the only alternative. It is to be kept in 
mind that the higher we ascend in the social scale the more 
frequently do we encounter pelvic deformities of varying de- 
grees, due to faulty development superinduced by lives of luxury 
and indolence, and that the class of patients coming under the 
care of the graduate nurse presents a far greater proportion of 
such deformities than is found among women in the lower walks 
of life. 
3 



Ill 

Anatomy (continued) 

THE FEMALE ORGANS OF GENERATION 

The female organs of generation are divided into two 
groups, the external and the internal, which are connected by the 
vagina. 

The external organs, taken as a whole (Fig. 8), constitute 
the vulva, and consist of — 




Fig. 8. — External organs of generation. A, A, labia majora ; B, B, labia minora? 
C, meatus urinarius; D, clitoris; E, mons veneris; F, perineum ; G, anus; H, entrance to 
vagina. 

The mons veneris, a firm, cushion-like formation covered 
with hair and lying directly over the symphysis pubis. 

The labia majora, or greater lips, made up of adipose tissue 

(fat) and covered externally with skin and hair and internally 

with mucous membrane. They begin in the median line at the 

lower border of the mons veneris and extend downward and 

34 



ANATOMY. 35 

backward, on either side, to meet at a point termed the four- 
chette, which is almost invariably torn at the first labor. 

The labia minora, or lesser lips, lie entirely within the vulva, 
except in the case of infants and of women who have borne chil- 
dren or are much emaciated. They are covered entirely with 
mucous membrane, and their upper extremities are divided into 
two parts, one passing above and one below (and so forming a 
hood for) 

The clitoris. This is a small reddish tubercle situated about 
half an inch behind the upper and anterior junction of the labia 
majora. 

The meatus urinarius, commonly spoken of as the " meatus/* 
is the external opening of the urethra, which is the canal (about 
one and one-half inches in length) leading to the bladder. The 
meatus lies directly back of the clitoris and about three-quarters 
of an inch from it. When the labia are separated it appears as 
a small dimple in the median line under the symphysis. 

The vagina is a musculo-membranous canal, five to six inches 
in length, leading from the vulva to the uterus and lying wholly 
within the true pelvis. It is lined with mucous membrane, the 
secretion of which possesses marked germicidal properties. In 
consequence of this fact the vagina is always aseptic except in 
the presence of disease or very soon after direct infection from 
without, and for this reason a vaginal douche should never be 
given before labor unless it is specially ordered by the physician. 
Under ordinary circumstances such a douche can do no good, 
and it is certain to do actual harm by removing the natural and 
aseptic lubricant of the vagina, even if it does not, through 
carelessness of preparation or administration, introduce infection 
where none had existed previously. 

The internal organs of generation (Figs. 9 and 10) consist of 
the uterus, the Fallopian tubes, and the ovaries. 

The uterus, or womb (Fig. 11), is a hollow, pear-shaped 
organ about three inches in length in the non-pregnant state. 
It is composed of muscular tissue, covered externally almost 
wholly with peritoneum and internally with mucous membrane, 
and is suspended in the pelvis by means of a number of ligaments 



36 A NURSE'S HANDBOOK OF OBSTETRICS. 

arranged in pairs and stretching across from the uterus to the 
sides of the pelvis or to other pelvic organs. This arrangement 
of the ligaments is such that the uterus is allowed considerable 
freedom of motion, and its position varies slightly with respira- 
tion, with the posture of the woman, and with the condition of 
the bowels and bladder. In other words, the uterus has no 




Fig. 9. — Internal organs of generation. (Keating and Coe.) Showing the uterus in its 
normal position between the bladder and the rectum. The vagina lies between the lower 
border of the bladder and the meatus urinarius above and the rectum and anus below, 
separated from the latter by the perineum. 

intimate attachment to any fixed point, but hangs in the pelvis 
in a way to permit of its enormous enlargement during preg- 
nancy, — from about the size of an egg before conception has 
occurred to that of a fairly large pumpkin at the time of labor. 
The uterus lies in about the centre of the pelvis, below the brim, 
with the bladder in front and the rectum behind, so that, of 



ANATOMY. 



37 




Fig. io— The internal organs of generation, seen from above. (Keating and Cpe.; 




Fig. it.— The uterus and its appendages. (Keating and Coe.) The ovaries are the almond- 
shaped bodies lying between the uterus and the extremities of the Fallopian tubes. 



38 



A NURSE'S HANDBOOK OF OBSTETRICS. 



necessity, a full rectum will force it forward and a distended 
bladder will tilt it backward. Its upper,, rounded border is called 
the fundus, and its lower, narrowed portion the cervix, while that 
part between the fundus and the cervix is termed the body of 
the uterus. The cervix projects into the vagina for a distance 
of about half an inch, much as a cork projects into the neck of 
a bottle. 




Fig. 12.— The cavity of the uterus. (Garrigues.) c, vagina; e, external os ; d, internal 
os : /, fundus, the letter being placed over the entrance of the Fallopian tube. 



The spaces between the sides of that part of the cervix which 
extends into the vagina and the vaginal walls are termed for- 
nices (plural of fornix), and are divided into four parts. The 
anterior fornix is between the anterior wall of the cervix and the 
anterior vaginal wall ; the posterior fornix is between the pos- 
terior vaginal wall and the posterior wall of the cervix; the 
lateral fornices are the spaces between the cervix and the vaginal 
walls on either side. 

The cavity of the uterus (Fig. 12) is lined with mucous 
membrane, and is divided into two parts, — the cavity of the body 
and the cavity of the cervix. The cavity of the body is tri- 



ANATOMY. 39 

angular in shape, with its apex pointing downward, while that 
of the cervix is spindle-shaped. 

There are three openings into the cavity of the uterus. The 
external opening, called the external os (Latin for mouth), is 
in the centre of the cervix as it projects into the vagina. It is 
very small in the non-pregnant state, barely admitting a probe, 
but at the time of labor it dilates to a size sufficient to permit the 
passage of the foetus. The other openings are at the upper angles 
of the triangular cavity of the body and lead into the Fallopian 
tubes, which will be described later. As the Fallopian tubes open 
directly into the peritoneal cavity, it will be seen that there is a 
direct avenue from the peritoneum to the outer world, through 
the Fallopian tubes, the uterus, and the vagina. 

The cavity of the cervix is slightly distended above the ex- 
ternal os, to become contracted again at its junction with that 
of the body. This second contraction is termed the internal os, 
and it is because of these two points of contraction that the 
cavity of the cervix acquires its spindle shape. 

The Fallopian tubes (see Fig. n) are two trumpet-shaped 
tubes, from four to five inches in length, extending from the 
upper angles of the uterus, just below the fundus, towards the 
sides of the pelvis. Between their outer extremities and the 
uterus, on either side, are found 

The ovaries (Fig. 13), which are the germ-producing organs 
of the woman and about the size and shape of an English walnut. 
Each ovary contains in its substance at birth a vast number of 
germs or ovules (from Latin, meaning "little eggs"), and, 
beginning at about the time of puberty and occurring at or about 
every menstrual period, one or possibly two of these ovules 
enlarges, approaches the surface of the ovary, escapes into the 
Fallopian tube, and so passes on into the uterus. 

The ovule which has " matured" in this way is the only one 
that can be impregnated by the male germ, and if there is no 
male element present in the Fallopian tube, where impregnation 
usually occurs, nothing results beyond the usual menstrual phe- 
nomena. 

The perineum (see Fig. 9) can hardly be considered as 



4 o 



A NURSE'S HANDBOOK OF OBSTETRICS. 



belonging to the organs of generation, but it may best be de- 
scribed in this chapter. Briefly, and as far as the nurse is con- 
cerned, it is the triangular mass of tissue which separates the 
vagina from the rectum. Its upper surface is covered by the 




9 



LQ* 



c :: 



Fig. 13. — Ovary and tube of a girl twenty-four years old. (Waldeyer.) U, uterus, 
T, tube; LO, ovarian ligament; o, ovary; x, limit of peritoneum ; b, cicatrices of ruptured 
Graafian follicles. 



lower wall of the vagina, its posterior surface is in contact with 
the rectum, and its external surface is covered with skin and 
lies between the lower angle of the vulva and the anus. The 
perineum forms the floor of the genital canal, and in certain 
difficult labors it is torn, when the head is born, to an extent 
varying all the way from a slight nick in the skin to a deep lacer- 
ation extending through the anus into the rectum itself. 

The mammae {mammary glands or breasts) are two highly 
specialized sebaceous glands located on either side of the an- 
terior wall of the chest between the third and seventh ribs. They 
secrete the milk which serves as the sole nourishment of the 
infant during the early months of its life, and they are abun- 
dantly supplied with nerves and blood-vessels and intimately 
connected, by means of the sympathetic system, with the uterus 
and other generative organs. This sympathetic relation is espe- 
cially noticeable when the infant nurses immediately after birth 



THE BREASTS. 



41 



and reflex uterine contractions result from the irritation of the 
nipple caused by the suckling. 

The breasts of a woman who has never borne a child are 
conical or hemispherical in form, but their size and shape vary 
greatly in women who have nursed one or more infants. 

The breasts are made up of glandular tissue and fat, and 
each organ is divided into fifteen or twenty lobes, which are 
separated from each other by fibrous and fatty walls and sub- 
divided into numerous lobules {little lobes) (Fig. 14). The 




Fig. 14.— Mammary gland of a woman during lactation, with lactiferous ducts and sinuses. 

(Luschka.) 

lobules are composed of acini (plural of acinus), in which the 
milk is formed, and as the ducts approach the nipple they are 
dilated to form little reservoirs in which the milk is stored, but 
contract again as they pass into the nipple. 

The external surface of the breast is divided into three por- 
tions, as follows : (a) The white, smooth, and soft area of 
skin extending from the circumference of the gland to the 
areola, (b) The areola, which surrounds the nipple and is of 



42 A NURSE'S HANDBOOK OF OBSTETRICS. 

a delicate pinkish hue in blondes and a darker rose-color in 
brunettes. Under the influence of gestation the areola becomes 
darker in shade, and this pigmentation which is more marked 
in brunettes than in blondes, constitutes, in many cases, a valu- 
able sign of pregnancy (see Figs. 31 and 36). (c) The nipple, 
a large conical papilla projecting from the centre cf the areola 
and having at its summit the openings of the milk ducts. 



IV 

Physiology 

OVULATION AND MENSTRUATION 

As stated in the previous chapter, the ovaries contain in their 
substance, at birth, a great number (about seventy thousand) of 
undeveloped ova or " eggs," and it is unnecessary to say that 
these ova are microscopical in size. 

Beginning, in this climate, at about the thirteenth year of 
age and occurring about" once a month, one of these ova enlarges 
and approaches the surface of the ovary. This enlarged ovum, 
lying directly under the surface of the ovary, constitutes what is 
known as the Graafian follicle (Fig. 15), and projects slightly, 




Fig. 15. — Longitudinal section through ovary of a woman twenty-two days after the last 
menstruation. (Leopold.) m.f., mature Graafian follicle; pr., most prominent point of 
follicle, where the rupture may be expected. 

like a small pimple. The Graafian follicle then becomes thinned 
at one point, where it soon bursts and allows the ovum to escape 
into the Fallopian tube (Fig. 16). 

43 



44 A NURSE'S HANDBOOK OF OBSTETRICS. 

Once within the Fallopian tube, the ovum makes its way into 
the uterus, and, if unimpregnated by the male element, it loses 
its vitality in a few days and is cast off with the menstrual flow. 




Fig. 16.— Longitudinal section of ovary of a woman on the first day of menstruation, 
with one burst follicle opening on the surface and other follicles in different stages of 
development. (Leopold.) 

When, however, the male germ is present it meets and pene- 
trates the ovum, usually while it is still in the Fallopian tube. 
The ovum thus impregnated passes on, as before, into the uterus, 
but instead of being cast out in the menstrual discharge it 
becomes adherent to the wall of the uterus and develops into 
the fcetus and its envelopes, the point of attachment to the uterine 
wall being the site of the placenta in later months. 

It is, of course, evident that of the vast number of ova con- 
tained in the ovaries, a comparatively small number ever mature 
and are prepared for fertilization by the male element, and that 
of these, so prepared by maturation and discharge from the 
ovary, very few are actually impregnated; for the impregnated 
ova of any woman are accurately measured by the number of her 
children plus the number of her miscarriages. 

This lavish provision of nature against any possible inter- 
ference with the propagation of the human race is also found in 
the male, for, of thousands of male elements (spermatozoa) 
deposited at one time within the vagina, very few make their way 
through the external os and the uterus to the Fallopian tube, 
and, of these, but one is successful in penetrating the wall of 
the ovum and causing pregnancy. 

Ovulation. — The process, by which the ovum develops 
and is cast out from the ovary into the Fallopian tube, to be 
impregnated or not, as the case may be, is termed ovulation, 



PUBERTY. 



45 



and while it is usually accompanied by menstruation, neither 
process is dependent upon the other. 

The accuracy of this last statement is shown by the follow- 
ing incontrovertible facts : Without ovulation there can be 
no pregnancy, and yet pregnancy has occurred before the es- 
tablishment of menstruation ; it has occurred after menstrua- 
tion has ceased ; and it not infrequently occurs during lactation, 
when menstruation is suppressed. On the other hand, menstru- 
ation may occur independently of ovulation, for it has been 
known to take place after the ovaries and tubes have been 
removed on both sides. 

Puberty. — Puberty, in females, is the time of life at which 
menstruation is first established, and occurs in the temperate 
zones about the thirteenth year. In tropical countries it is as 
early as the eighth or ninth year, while in the extreme north it 
may be delayed until the seventeenth or eighteenth year. 

Adolescence, which is the period between puberty and 
maturity, is characterized by rapid physical changes. The ex- 
ternal genitals enlarge and the pubic hair appears. The hips 
broaden and the breasts enlarge. Along with the physical are 
psychical developments. The girl rapidly matures in mind and, 
unless properly directed, the lack of established mental balance 
may become serious. This transition period, from girlhood to 
womanhood, is one of the most critical in the life of every 
woman. Delicately bred girls require special safeguarding to- 
ward the end of perfect physical development. 

Proper hygienic conditions with regard to food, exercise, 
fresh air and sleep, with an entire absence of excitement, is to 
be insisted upon. Excessive study is contraindicated, and the 
habit of spending the first day of menstruation in bed or until 
all pain has disappeared is the only safe rule to follow. 

Menstruation. — This is the periodical discharge of blood 
from the cavity of the uterus, and occurs throughout the child- 
bearing period at regular intervals of about twenty-eight days, 
except during pregnancy and lactation, when it is usually sup- 
pressed entirely. Next to twenty-eight days the most common 



4 A NURSE'S HANDBOOK OF OBSTETRICS. 

interval is thirty clays. Occasionally it occurs every twenty- 
one days without any appreciable derangement of health. The 
duration of the flow should be from four to five days and the 
amount of blood lost from five to six ounces. Regularity is the 
chief characteristic of a normal menstruation. At the begin- 
ning and again at the end of the menstrual life, marked ir- 
regularity may persist for from one to two years. In normal, 
well-developed women, when no constitutional disease exists, 
the symptoms preceding and accompanying the flow may be 
a feeling of weight and congestion in the pelvis, fulness and 
tingling in the breasts, and slight headache or backache. 

Excessive pain before or during the menstrual period, if 
accompanied by general symptoms, points to some disturbance 
of the pelvic organs, which, in turn, may be due to constitutional 
disease. 

In another very large class of women, the symptoms ac- 
companying menstruation are far more severe. The sensation 
of weight and congestion in the pelvis becomes excruciating, 
the backache almost unbearable, and with the intense head- 
ache may be associated nausea, or even vomiting of a distress- 
ing type. Where there is no deformity or disease, these cases 
may be controlled in youth by hygiene, later by a normal in- 
terest in the great world of out-of-doors. Monotony and 
confinement lead to morbid introspection or violent excitement. 
These cases are largely found in the extremes of indolence, and 
luxury, on the one hand, and great poverty and privation, on 
the other hand ; and the women who suffer in this way are 
usually pale, thin, and anaemic, though occasionally stout and 
plethoric. 

All marked abnormalities of menstruation are of direct ob- 
stetrical importance ; for a patient presenting such abnormal 
symptoms is certainly suffering from the effects of a displaced 
or undeveloped uterus, and a deformity or slight contraction 
of the pelvis will be found in a fair proportion of cases. 

Menopause. — The menopause, climacteric, or "change of 
life," occurs at or about the forty-third year. Before menstru- 



MENSTRUATION. 47 

ation ceases, the periods become irregular for a few months. 
The majority of women are apt to suffer nervously and often 
develop vague hysterical symptoms. 

Pregnancy may occur at this age and a patient may regard 
the cessation as indicating this. Nurses need only to be re- 
minded that discussion of a diagnosis must be conservative 
and the patient should be referred to her physician. 



Physiology (continued) 



FETAL DEVELOPMENT 



The ovum, originating in the ovary and discharged through 
the Graafian follicle at or about the time of menstruation, passes 
into the Fallopian tube, where, if pregnancy is to occur, it meets 
the male element or spermatozoon. The spermatozoon, shaped 




t~ 



Fig. 17.— Human spermatozoa. (Retzius.) A, front view of a spermatozoon ; B, side view ; 
h, head ; m, middle piece; I, tail; e y end piece. 

like a tadpole, with head and long tail (Fig. 17), penetrates the 
wall of the egg-like ovum and conception has taken place. 

The interior of the ovum, corresponding somewhat to the 
yolk of an egg and now containing the spermatozoon, divides 
into two parts, each part containing half of the yolk and half of 
the spermatozoon. Each of these parts divides in the same way, 
and each subdivision again divides and subdivides until the 
interior of the ovum is filled with a mass of minute divisions of 
the original yolk and spermatozoon (Fig. 18). These are called 
" cells," and keep on dividing and subdividing in the same man- 
ner to form the foetus and its envelopes. As each separate cell 
48 



THE OVUM. 



49 



contains part of the maternal element (ovum) and part of the 
paternal element (spermatozoon), it is not difficult to under- 
stand why the child partakes of the characteristics of both 
father and mother. 




Fig. 18. — First stages of segmentation of the ovum of a rabbit. (Allen Thomson, aftei 
Edward van Beneden's description.) 



During this process of subdivision of the ovum, which is 
called segmentation, the entire mass passes slowly on through 
the Fallopian tube until it emerges into the cavity of the uterus. 
Once within the cavity, it lodges in one of the folds of the 
mucous lining, usually in the region of the fundus, and the bor- 
ders of this fold reach up around it to hold it firmly and prevent 
its dislodgement (Fig. 19). 

The mucous membrane lining the uterus undergoes certain 
changes at each menstrual period, and, as it was formerly sup- 
posed to be cast off with the menstrual flow and a new mem- 
brane formed before the next period occurred, it was called 
decidua (Latin, deciduus, falling off). It it now understood 
that little or nO tissue from the lining of the uterus is lost in 
the monthly discharge, but the old name is still retained, al- 
though the elaborate distinctions between the " decidua of men- 
struation" and the " decidua of pregnancy" are no longer dis- 
4 



5° 



A NURSK'S HANDBOOK OF OBSTETRICS. 



cussed as formerly. Upon the occurrence of pregnancy there 
can be, of course, no " falling off "of the uterine lining, no 
matter what may once have been thought to have taken place 
at the monthly flow, or the ovum itself would be cast away at 
the same time and abortion or miscarriage would result. 

The uterine lining contains a vast number of little creases 
or folds and the impregnated ovum, after passing from the 
Fallopian tube into the uterus, lodges in one of these and be- 
comes securely attached to the mucous membrane, usually near 
the upper part of the organ, as has already been said. Once 
securely fixed at this point, the walls of the fold in which the 
ovum is lodged begin to grow up around it until they meet 
and enclose it as in a shell. This little shell, containing the 
impregnated ovum, is made up of decidua, and there is other 
decidua lining the rest of the uterine cavity upon which this 
" shell" and its contents lie, much as would a wart in the palm 
of tht hand when the hand was tightly closed. 

Thus we have, in pregnancy, three kinds of decidua, — (a) 
that upon which the ovum rests as soon as it lodges in the fold 
of the mucous membrane, called decidua serotina; (b) that 
which folds up around the ovum to encapsulate it, called decidua 
reflexa; and (c) that which lines the remainder of the uterine 
cavity, called decidua vera or " true" decidua. 

These terms, " decidua serotina" and " decidua reflexa," date 
back to the time when it was believed that the uterine lining 
was cast off at every menstruation, and before any very clear 
understanding had been reached as to the manner of the forma- 
tion of the decidua of pregnancy. At the present day the ex- 
pressions decidua basilis and decidua capsularis, respectively, 
are undoubtedly in better usage, but as they are not so gen- 
erally accepted they will receive no further notice here. 

As the ovum enlarges, the decidua reflexa also increases in 
size until, at about the fourth month when the embryo entirely 
fills the uterine cavity, it meets and blends with the decidua vera 
at every point. 

On the decidua serotina, or point of attachment between the 
impregnated ovum and the uterine wall, is formed what is known 



THE DECIDUA. 



51 



as the placenta, through which the foetus receives its nourish- 
ment and oxygen from the mother and which will be described 
later. 

The dccidua reflexa, both before and after it has blended with 
the decidua vera, forms the outer covering of the amniotic sac, 




Fig. 19.— Uterus with decidua in beginning pregnancy. (Ruge.) o.i., internal os ; o, 
ovum, covered by decidua reflexa; d, decidua vera. 



or " bag of membranes," which is lined with a transparent mem- 
brane called the amnion and filled with a pale, straw-colored 
liquid, the amniotic fluid or liquor amnii, in which the foetus 
floats. 

Considering, now, the foetus at or near the time of labor, we 
find it floating in a straw-colored liquid, which is contained in 



52 A NURSE'S HANDBOOK OF OBSTETRICS. 

a sac, the "bag of membranes," or amniotic sac, and which lies 
within the uterus and fills it entirely (Fig. 20). 

The function of the amniotic sac is to protect the foetus from 
blows or other injuries that may be inflicted on the mother, while, 
at the same time, allowing it considerable freedom of motion ; 
to provide it with nourishment and oxygen through the placenta ; 
and. at the time of labor, to dilate the neck of the uterus by 
forcing its way down through the internal os and stretching the 
cervix in every direction. 




Fig. 20.— Normal position of foetus in utero. (Garrigues.) Extremities completely 
flexed ; occiput presenting, and back of child to left of mother and directed towards the 
front. (First, or left occipito-anterior, position, — " L. O. A.") 

Except at one point, which corresponds to the point of at- 
tachment of the impregnated ovum to the uterine wall, the 
amniotic sac consists of three layers. The inner, called the 
amnion, which secretes the liquor amnii, is thin and transparent ; 
the middle layer, called the chorion, is thicker and translucent ; 
while the outer layer is made up of decidua reflexa and decidua 
vera fused together. 



THE PLACENTA. 53 

At the point of attachment of the ovum to the uterine wall, 
however, a different formation is found. Instead of a thin, veil- 
like membrane, a thick spongy mass, called the placenta, is de- 
veloped. It, too, is covered on its inner (fetal) surface with 
amnion, under which is a layer of chorion, but its outer surface 
is composed of decidua serotina. 

The placenta (Figs. 21 and 22) is a circular mass about 
eight inches in diameter, one to one and a half pounds in weight, 
and one inch in thickness at its centre, thinning out considerably 
towards the periphery. It forms part of the bag of membranes, 
and may be regarded as a large thickened area in the sac, 
attached firmly to the uterine wall. 

It is made up almost wholly of blood-vessels, which throw 
out loops into the uterine tissue to interlock with somewhat 
similar loops in the vessels of the uterus, but there is no direct 
connection between the uterine and placental vessels and no 
actual interchange of blood. The blood of the foetus is pumped 
by the fetal heart through the placental vessels, and gives up 
its waste products to, and takes on oxygen from, the maternal 
blood, much as the blood of an adult is oxygenated by passing 
through' the lungs in vessels that lie closely in contact with the 
air-spaces. This process, by which waste products and oxygen 
can pass from fetal to maternal blood, and vice versa, through 
the walls of the vessels without any actual mingling of the blood 
currents, is called osmosis. 

The placenta and fcetus are connected by means of the funis, 
or umbilical cord, usually about twenty inches in length and the 
size of the forefinger. It leaves the placenta at about its centre 
and enters the abdominal wall of the fcetus at a point called the 
umbilicus, or " navel," a trifle below the middle of the median 
line in front. 

The placenta is formed during the second month of gesta- 
tion, but is not fully developed until the third month, after which 
it steadily increases in size as pregnancy advances. 

The umbilical cord is formed about the fourth week, and, 
like the placenta, increases in size with the advancement of 
pregnancy. It is made up of two arteries and one large vein, 



54 



A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. ai.-Fetal surface of the placenta. (Garrigues.) The filmy membrane about the 
circumference is the ruptured amniotic sac. 




Fig. 22.-Maternal surface of the placenta. (Garrigues.) 



THE FCETUS. 55 

which are twisted upon each other, and these are protected by 
a soft, transparent, bluish-white, gelatinous substance called 
" Wharton's jelly." 

During the early months of pregnancy the foetus, or " em- 
bryo," as it is usually called, bears no resemblance whatever 
to the human form. At the end of four weeks the ovum (Fig. 
23) is merely a spongy-looking sphere containing a small, 
curved, gelatinous mass, with no evidence of head or extremities 
(Fig. 24), and if an abortion occurs at this time it is almost 
invariably lost in the discharge of blood. 

By the end of the third month it has increased considerably 
in size, being about four inches in length and weighing about 




Fig. 23. — Human ovum at the end of the first month. Actual size. (Wood's Museum, 
Bellevue Hospital, No. 1193.) 

three and one-half ounces (Fig. 25). The head is now devel- 
oped, and is by far the largest part of the fcetus, being nearly 
one-third its entire size. The neck and extremities are also 
formed and the fingers are separated. The skin is of a pale 
rose-color and very thin and delicate. The placenta is distinctly 
developed, and the genital organs are formed sufficiently to per- 
mit recognition of the sex. From this time on the embryo is 
called the foetus. 

Development progresses rapidly as the weeks go by, and at 
the end of the sixth month marked changes have occurred. 
The fcetus is now about twelve inches long and weighs about 



56 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 24. — Outline of human embryo of about four weeks. Enlarged four times. (Allen 

Thomson.) 




Fig. 2.5 — Human foetus at the end of the third month. Three-fifths actual size 
(Garrigues.) 



THE FCETUS. 



57 




Fig. 26.— Skeleton of infant at term, showing large head, large anterior fontanelle, 
small thorax, cartilaginous sternum, tilted pelvis, and bow-legs. Warren Museum, Harvard 
University. (Rotch.) 



58 A NURSE'S HANDBOOK OF OBSTETRICS. 

a pound. Faint evidences of the eyelashes and eyebrows have 
appeared, and the skin is darker and firmer. 

During the seventh month development is extremely rapid, 
and by the end of this period the fcetus is about fifteen inches 
long and weighs from three to four pounds. The eyelids can 
now be opened, and the skin is firmer, lighter in color than 
before, and covered with a greasy, sebaceous deposit, called 
"vernix caseosa," which is most abundant in the folds of the 
integument, and especially in the axillae and groin. This is 
probably the earliest time at which a child can be born with any 
reasonable prospect of living. 

During the eighth month development is slower, and by the 
end of the ninth, or at " full term," the infant is plump, com- 
pletely formed, and ready to perform the functions of respira- 
tion, digestion, and excretion. It is from eighteen to twenty- 
two inches in length and weighs from six and one-half to 
seven and one-half pounds. The nails are fully developed and 
reach the ends of the finger-tips, the hair is long and full, 
and the skin is firm and paler than at any other previous 
time. 

The head of the fully developed foetus (Fig. 26) is still the 
largest part of its body, although it has been growing propor- 
tionately smaller throughout the entire period of gestation. It 
is oval, or egg-shaped, and it is divided into two parts, the 
cranium and the face. 

The cranium (Fig. 27) is the portion possessing the greatest 
obstetric importance, because, if it can pass safely through the 
pelvic canal, there is seldom, if ever, any difficulty in delivering 
the rest of the body. It is made up of eight bones, joined 
together firmly at the base but separated at the vertex, or top 
of the head. The sphenoid, ethmoid, and tzvo temporal bones 
lie at the base of the cranium, and are of no interest to the 
obstetric nurse. 

The frontal, occipital, and two parietal bones are, however, 
of great importance, and form the upper part of the cranium, 
separated at the time of birth by membranous intervals called 
sutures, the intersections of which are termed fontanelles. 



THE FGETUS. 



59 




6o A NURSE'S HANDBOOK OF OBSTETRICS. 

By means of this formation of the fetal skull the bones can 
overlap each other somewhat during labor and so diminish 
materially the size of the head during its passage through the 
pelvis. This process of overlapping is called " moulding/' and, 
after a long labor with a large child and a snug pelvis, the head 
is often so well moulded that several days elapse before it 
returns to its normal shape. 

The sutures of the cranium are five in all, but those sepa- 
rating the parietal and temporal bones on either side are unim- 
portant, as they cannot be reached by the examining finger 
during labor. 

The coronal suture separates the frontal from the two parie- 
tal bones, the lambdoidal suture separates the occipital from the 
parietal bones, and the sagittal, or " greater suture " divides 
the frontal bone into two parts, crosses the coronal suture, 
separates the parietal bones from each other, and ends at the 
lambdoidal suture behind. 

The anterior fontanelle, large and diamond-shaped, is at 
the intersection of the sagittal and coronal sutures, while at the 
junction of the sagittal with the lambdoidal suture is the small, 
triangular, posterior fontanelle. 

The sutures and the posterior fontanelle ossify shortly after 
birth, but the anterior fontanelle remains open until the child 
is over a year old, constituting the familiar " soft spot" just 
above the forehead of an infant. 

By feeling one or another of the sutures or fontanelles, and 
considering its relative position in the pelvis, the physician is 
enabled to determine accurately the position of the head at the 
beginning of labor. 

The foetus lies in the uterus in a state of complete flexion. 
Its body is arched forward, its head is bent upon the chest, 
its arms lie close to its body, with the forearms flexed and 
crossed in front. The thighs are flexed upon the body and the 
legs upon the thighs, while the feet are crossed like the hands. 
In nearly all cases the head points downward and the breech 
lies at the fundus. This is probably because the head, being 
the heaviest part of the foetus, would naturally sink to the lowest 
part of the uterus. 



FETAL CIRCULATION. 6i 

The foetus receives its nourishment and oxygen from the 
mother's blood into its own through the medium of the placenta. 
The fetal heart pumps blood through the umbilical cord into 
the placental vessels, which, looping in and out of the uterine 
tissue and lying in close contact with the uterine vessels, per- 
mit an interchange, through their walls, of waste products from 
child to mother and of nourishment and oxygen from mother 
to child. As has been said, this interchange is effected by the 
process of osmosis, and there is no mingling of the two blood- 
currents. In other words, no maternal blood actually goes to 
the foetus, nor does any fetal blood reach the mother. 

The fetal circulation is so arranged that this passage of 
blood to the placenta through the umbilical arteries and back 
through the umbilical vein is possible up to the time of birth, 
but ceases entirely the moment the child breathes and so begins 
to take its oxygen directly from its own lungs. 

In order to understand, even in a general way, the course 
of the fetal blood-current, it must be borne in mind that, in the 
infant after birth, as in the adult, the venous blood passes from 
the two vense cavae into the right auricle of the heart, thence to 
the right ventricle, and through the pulmonary artery to the 
lungs, where it gives up its waste products and takes on a fresh 
supply of oxygen. After oxygenation the so-called arterial blood 
flows from the lungs, through the pulmonary vein to the left 
auricle, thence to the left ventricle, and out through the aorta, 
to be distributed to all parts of the body and eventually collected, 
as venous blood, in the two venae cavse and discharged again into 
the right auricle (Fig. 28). 

In the foetus there are certain structures necessary to the 
performance of fetal circulation, but of no use after respiration 
has commenced and the flow of blood through the umbilical and 
placental vessels has ceased. Consequently these structures are 
abandoned as soon as the child cries, and shortly after birth 
they either disappear entirely or are converted into fibrous cords, 
and remain in after life as fetal structures only. 

The most important of these, and the one that must close 
promptly and effectually at birth if the child is to live for any 



62 



A NURSE'S HANDBOOK OF OBSTETRICS. 



DESC:,. 

VENA J 
CAV/F 




ARTERIAL BLOOD 

p]a§ VENOUS BLOOD 
Fig. 28.-Diagram of circulation after birth. Adult type. 



FETAL CIRCULATION. 



63 







A5CE 
VENA 
CAVA 



RIGHT 

ventricle; 



[^Wns 




[jjjj ARTERIAL BLOOD 
|&&| VENOUS, BLOOD 

Fig. 29. — Diagram of circulation before birth. Fetal type. 



64 A NURSE'S HANDBOOK OF OBSTETRICS. 

length of time, is the foramen ovale, — a valve-like opening 
between the right and left auricles. The others are the ductus 
arteriosus, connecting the aorta and the pulmonary artery; the 
ductus venosus, connecting the umbilical vein and the ascending 
vena cava; and the two hypogastric arteries, springing from 
the internal iliacs and passing out of the abdomen, through the 
navel, into the cord, where they become the umbilical arteries. 

Keeping in mind the course of the blood-current after birth, 
when these fetal structures have ceased to exist as blood-passages, 
we can trace the fetal circulation from the placenta, where it is 
oxygenated before birth, back to its starting-point (Fig. 29). 

The arterial (oxygenated) blood flows up the cord through 
the umbilical vein and passes into the ascending vena cava, 
partly through the liver but chiefly through the ductus venosus 
which connects these two vessels. It is because of the fact that 
the liver receives a considerable supply of freshly vitalized blood 
direct from the umbilical vein that it is, proportionately, so large 
in the newly born child. 

From the ascending vena cava the current flows into the right 
auricle and directly on to the left auricle through the foramen 
ovale, thence into the left ventricle, and out through the aorta. 
The blood which goes up to the arms and head returns through 
the descending vena cava to the right auricle again, but instead 
of passing through the foramen ovale as before, the current is 
deflected downward into the right ventricle and out through the 
pulmonary artery, partly to the lungs (for purposes of nutri- 
tion only), and partly again into the aorta through the ductus 
arteriosus. 

The blood in the aorta, with the exception of that which goes 
to the head and upper extremities, and which has already been 
accounted for, passes downward to supply the trunk and lower 
limbs. The greater part of this blood finds its way through the 
internal iliacs to the hypogastric arteries, and so back through 
the cord to the placenta, where it is again vitalized ; but a small 
amount passes back into the ascending vena cava, partly through 
the liver and partly from the lower extremities, to mingle with 
fresh blood from the umbilical vein and again make the circuit 
of the entire body. 



MULTIPLE GESTATION. 65 

As soon as the child is born it cries and inflates its lungs. 
This causes the ductus arteriosus to contract, and blood no 
longer passes from the pulmonary artery into the aorta. At 
the same time the foramen ovale closes and the blood from the 
venae cavse, which is discharged into the right auricle, passes 
at once into the right ventricle, to be sent through the pulmonary 
artery to the lungs for oxygenation. 

When the cord is tied and cut the current of blood through 
the umbilical vessels (arteries and vein) ceases and the blood 
is dammed back through the hypogastric arteries to the internal 
iliacs and shut off completely in the umbilical vein and ductus 
venosus. 

These processes, which occur instantaneously, change the 
entire course of the blood-current and convert the fetal circu- 
lation into the ordinary adult type. The foramen ovale remains 
closed and eventually disappears, and the ductus arteriosus, 
ductus venosus, and hypogastric arteries shrivel up and are con- 
verted into fibrous cords in the course of ten or fifteen days. 

When, as occasionally happens, two or more embryos develop 
in the uterus at the same time the condition is known as multiple 
gestation. 

This is of very rare occurrence, twins being encountered but 
once in 90 pregnancies, triplets but once in 8000, and quadruplets 
but once in 370,000. These figures, of course, vary considerably, 
but they serve to show the extreme rarity of multiple concep- 
tions. 

In twin pregnancies the most common combination of sex is 
a boy and a girl ; the next in frequency is two boys ; and the 
least common of all is two girls. 

Heredity plays an important part in the causation of twins, 
often making certain families conspicuous on this account, and 
the hereditary trait is most frequently handed down through the 
father. 

Twins are usually due to the fertilization of two separate 
ova, either from the same or from different Graafian follicles, 
but they may result from the double impregnation of a single 
ovum by two spermatozoa or from the complete fusion of a 
single germ. 



36 A NURSE'S HANDBOOK OF OBSTETRICS. 

Triplets come from the double impregnation or complete 
fusion of one ovum and the simultaneous single fertilization of 
another, while quadruplets may be regarded as double twins. 

In the case of twins it is to be borne in mind that as both 
umbilical cords may come from the same placenta, the maternal 
end of Hie cord attached to the first-born must be tied securely 
before it is cut, lest the unborn child bleed to death. The nurse, 
from whom skill in ante-partum diagnosis is not to be expected, 
should make it a point to tie securely both the fetal and the ma- 
ternal end of every cord before cutting, in view of the possi- 
bility of the existence of twins. 

The development of the foetus in multiple pregnancies does 
not differ from that of single impregnation, except that the in- 
fants are apt to be small and feeble, usually one being decidedly 
weaker and more frail than the other. 



VI 

The Physiology of Pregnancy 

By the physiology of pregnancy is meant a consideration 
of those changes, both local and general, which affect the 
maternal organism as a result of pregnancy, but which sub- 
side at or before the end of the puerperium and leave the 
woman in practically the same condition in which she was 
before conception occurred. In other words, these changes are 
to be regarded as normal, unavoidable, and purely temporary, 
for they are present in varying degree in every instance, and 
in the case of a physically perfect woman there should be no 
traces of them left after convalescence is complete. It must 
be understood that this statement does not refer to certain 
skin-markings, which will be described later, or to the slight 
and unimportant lacerations of the genital tract which in- 
variably accompany a first labor, but only to such conditions as 
would have a tendency to affect the general health or even the 
comfort of the woman. 

Local Changes. — The uterus increases in size to make 
room for the growing foetus. It becomes more vascular and 
the thickened, growing mucous membrane becomes the de- 
cidua of pregnancy. At the end of four months it has risen 
out of the pelvis. Its muscular walls become much stronger and 
more active, and the abdomen must enlarge to accommodate the 
growing uterus. 

The mechanical effect of this distention of the abdominal 
wall causes, in the later months of pregnancy, the formation 
of certain reddish or bluish streaks in the skin covering the 
sides of the belly and the anterior and outer aspects of the 
thighs. These streaks are known as "stria gravidarum" or 
"linece albicantes," and are due to the stretching, rupture, and 
atrophy of the deep connective tissue of the skin. They grow 
lighter after labor has taken place, and finally take on the 

67 



68 



A NURSE'S ll.wnnOOK OF OBSTETRICS. 



silvery whiteness of cicatricial tissue. In subsequent preg- 
nancies new reddish or bluish lines may be found mingled with 
old silvery white striae. 




Fig. 30. — Strias gravidarum, or Lineae albicantes, showing also abdominal pigmenta- 
tion especially marked around navel, and protrusion of umbilicus. Multigravida at 
term. Twins. 

The number, size, and distribution of stricc gravidarum vary 
exceedingly in different women, and patients are occasionally 
seen in whom there are no such markings whatever, even after 
repeated pregnancies. 

As the striae are due solely to the stretching of the cutis, 
they are not peculiar to pregnancy, but may be found in other 
conditions which cause great abdominal distention, such as 
dropsy and the presence of large tumors of rapid growth. 



PHYSIOLOGY OF PREGNANCY. 69 

Coincident with the uterine and abdominal enlargement the 
umbilicus is pushed upward until, at about the seventh month, its 
depression is completely obliterated and it forms merely a dark- 
ened area in the smooth and .tense abdominal wall. Later it is 
raised above the surrounding integument and projects to about 
the size of a hickory-nut. 

While these changes in the uterus and abdomen are going on 
the vagina and external genital organs are being prepared for 
the passage of the foetus at the. time of labor. The parts are 
thickened and softened and their vascularity is greatly increased. 
This increase in the blood-supply of the genital canal gives to 
the tissues a dark-violet hue, in great contrast to the ordinary 
pinkish color of the parts, and often described as a valuable 
sign of pregnancy. 

Towards the end of gestation the vaginal secretion is in- 
creased in amount to serve as a lubricant at the time of delivery. 

The changes in the breasts are such as will prepare these 
organs for the performance of nursing, and begin to show them- 
selves shortly after the occurrence of conception (Fig. 31). The 
breasts become larger, firmer, and more prominent, and the 
nipples increase in size, grow sensitive, and are easily stimulated 
to erectility. The pinkish areola about the nipple of the woman 
who has never borne a child grows larger and darker until it 
becomes brown or, in some cases, almost black. This change 
in the color of the tissue surrounding the nipple is most pro- 
nounced in decided brunettes and less marked in women of the 
blonde type. The sebaceous glands which surround the nipple 
to the number of about a dozen, and are known as the " glands 
of Montgomery," become enlarged into little rounded elevations 
under the influence of pregnancy, and are then called the " tu- 
bercles of Montgomery" (see Fig. 41.) 

The distention of the skin covering the breasts also causes 
the formation of " striae" similar in every respect to those already 
described as occurring in the abdominal integument. Like the 
abdominal striae, these markings vary greatly in different sub- 
jects and not infrequently are entirely absent. 

After the third month the breasts contain a thin, bluish-white, 



7 A NURSE'S HANDBOOK OF OBSTETRICS. 

translucent fluid known as " colostrum," consisting chiefly of 
fat corpuscles, epithelial cells, and " colostrum corpuscles." 
Colostrum is the only substance secreted by the breast until 
about the third day after labor, when the true milk is formed. 
It contains practically no nourishment, but is of value to the 
infant during the early days of its life because of its marked 
laxative effect. 

Systemic Changes. — The blood of the pregnant woman 
is increased in amount and in its fluid constituents, while the 
red cells are proportionately diminished. These changes fre- 
quently cause disturbance of the circulatory apparatus and the 
left side of the heart is appreciably enlarged in order to per- 
form the extra work of pumping this increased quantity of 
blood through the body. In certain cases the fluid constituents 
of the blood are increased to such a degree that marked swell- 
ing (oedema) of the legs, thighs, and external genitals may 
occur. This oedema must not be confused with that due to 
kidney disorder; and any swelling of the extremities must be 
reported at once to the physician. 

The lungs are subjected, in the later months of pregnancy, 
to pressure from the underlying uterus, and the patient may 
suffer severely from cough and dyspnoea. Owing to the in- 
crease in the total quantity of the maternal blood, and because 
of the fact that the mother is called upon to oxygenate not only 
her own blood, but, by osmosis, that of her infant as well, the 
work of the lungs is markedly increased and the elimination 
of carbonic acid gas is much greater than in the non-pregnant 
state. 

The digestive, secretory, and excretory organs are likewise 
taxed to a high degree ; for the pregnant woman must, in order 
to nourish both her child and herself, form more blood, digest 
more food, and excrete more waste products. After a few 
weeks these increased demands on the digestive organs begin 
to manifest themselves by causing nausea and vomiting, and 
the patient is fortunate if these symptoms do not cause her 
great distress up to about the middle of gestation. 



VII 

The Phenomena of Labor 

Labor occurs at the end of pregnancy, and is also known by 
the various names of "delivery" "confinement," "lying-in" 
and "parturition." 

The usual time for labor to take place is two hundred and 
eighty days (ten lunar months, or nine calendar months) after 
the occurrence of conception. This period varies somewhat, and 
it is possible for a child to be born and live after only about two 
hundred and twenty days of utero-gestation. These cases are, 
of course, extremely rare, and it goes without saying that the 
more nearly the pregnancy reaches its normal duration the better 
will be the development of the child and the better its chances for 
living. The only exceptions to this rule are in cases where the 
mother is suffering from a disease that greatly imperils the life 
of the child, or where the child is very large or the pelvis very 
small, and the induction of premature labor exposes the infant 
to less risk than would a difficult operative delivery at full term. 

The popular belief that a seven-months baby has better 
chances for life than one born at eight months is the most arrant 
nonsense. It probably arises from the fact that a child born at 
seven months is positively known to be premature, and so re- 
ceives the most careful attention after birth, while an eight- 
months baby is so nearly a full-term infant that its prematurity 
is often overlooked and it receives no special attention, and 
may die from some inadvertent neglect of small but important 
details. After it is dead the fact that it was one month prema- 
ture is brought out and commented upon. 

In other cases the pregnancy may exceed its usual duration 
of two hundred and eighty days, but probably it never goes more 
than three weeks over term under any circumstances, and three 
hundred days may be regarded as the extreme limit. In France 
t 1 rj"s point has been made a matter of legislation, and an infant 

75 



;<> A NURSE'S HANDBOOK OF OBSTETRICS. 

born at any time within three hundred days after the death of 
its mother's husband is regarded by law as legitimate and enti- 
tled to property rights in the father's estate, while one born even 
twenty-four hours after this period is deprived of the right of 
inheritance. 

The cause of labor is probably due to the fact that at the 
end of pregnancy the uterus is stretched to its greatest possible 
extent, while the foetus continues to grow larger. The muscular 
fibres of the uterus resent this over-distention and put an end to 
it by contracting and forcing the foetus out of the womb. This 
theory is borne out by the fact that in twin pregnancies, or in 
other cases where the uterine contents is unusually large, prema- 
ture labor is very likely to occur, showing that when a certain 
degree of distention is reached labor will begin. 

The premonitory symptoms of labor are usually well 
marked in the case of a first pregnancy, but in some instances, 
and especially with women who have borne children, they may 
be entirely absent. When they do occur they may begin at any 
time up to two, or even three, weeks before the actual onset of 
labor. They are due chiefly to the sinking down of the uterus 
into the pelvis preparatory to the engagement of the fetal head 
in the pelvic brim. This relieves the pressure on the diaphragm 
and so lessens or stops the cough, dyspnoea, and other unpleasant 
symptoms of the last weeks. While the sinking of the uterus 
relieves the pressure above the diaphragm, it increases that on 
the pelvic viscera, causing constipation and irritability of the 
bladder. On the whole, however, the woman feels more com- 
fortable than she did before the sinking of the uterus. In addi- 
tion to the symptoms due to alterations in pressure there are 
occasional slight uterine contractions occurring at irregular inter- 
vals and causing the woman no discomfort beyond sensation 
of faint and indefinite cramp-like pains in the abdomen. 

Labor is divided, for convenience of description, into three 
distinct stages. 

The first stage begins with the first true labor-pain and ends 
with the complete dilatation of the os uteri. 

The second stage begins with the end of the first and ends 
with the birth of the child. 



STAGES OF LABOR. 



77 



The third stage begins with the end of the second and ends 
with the delivery of the placenta and membranes. 

In normal cases the first stage is longer than the second and 
third together, for after the os is fully dilated the labor pro- 
gresses rapidly. 

Labor-pains are merely the rhythmical contractions of the 
uterine muscle, and are called " pains " because of the suffer- 
ing that accompanies them. The incorrectness of the term is 
evident when one occasionally hears a woman say, " I always 
have easy labors ; my pains never hurt me at all." The term 
is synonymous with uterine contraction. 

The Phenomena of the First Stage. — The pains are 
short, slight, and separated by long intervals, usually about half 
an hour. They do not cause the patient any particular discom- 
fort, and are not accompanied by any straining of the abdominal 
muscles. What little pain there is is located in the back, and 
the patient is usually on her feet and walking about. If the 
woman has never borne a child or seen a labor, she is commonly 
in rather a jocular frame of mind, and often expresses great 
contempt for the reputed suffering of child-birth. 

A little later, however, the entire picture changes. The pains 
last longer and are more severe, and recur at more frequent 
intervals. The patient is still walking about, but at the begin- 
ning of each pain she grasps a chair-back or some other piece of 
furniture, and, leaning heavily against it, " grunts " audibly when 
the pain is at its height. Even now the pains are not specially 
severe, and between them the patient is usually cheerful and still 
of the belief that labor is not such a terrible thing after all. As 
the hours go by the pains become more and more frequent, until 
they are only five or six minutes apart, while at the same time 
they last longer and are more severe. The patient is now tired 
and fretful, and begins to complain bitterly that the end will 
never come and that something must be done to relieve her. 
Her entire disposition changes and her face bears an expression 
of anxiety and dread. She may be nauseated, or even vomit, 
and her bowels and bladder are emptied every few minutes. At 
the acme of each pain she usually moans slightly, and in the 



;S A NURSE'S HANDBOOK OF OBSTETRICS. 

intervals she says little, except to ask for water, or other attention, 
and complain of the slow progress she is making. 

This picture indicates that dilatation of the os uteri is nearly, 
if not entirely, complete, and the nausea and vomiting are favor- 
able symptoms for they are accompanied by relaxation of the 
tissues. 

At or about this time the amniotic sac, which, from the begin- 
ning of labor, has been forcing its way down through the os 
and dilating it in every direction, usually ruptures and the fluid 
escapes with an audible gush. 

Even without a vaginal examination it is usually easy to tell 
from the appearance of the patient that the first stage of labor 
is at an end. It may have lasted anywhere from one to twenty- 
four hours, and is always protracted if the membranes rupture 
before dilatation of the os is complete. 

The Phenomena of the Second Stage. — The patient is 
now in bed and the pains are severe, long (fifty to one hundred 
seconds), and occur at intervals of every two or three minutes. 

The abdominal muscles are now brought into play, and as a 
pain occurs the woman " bears down " with all her strength, so 
that her face becomes red and even cyanotic, and the large vessels 
in her swollen neck pulsate violently. At the beginning of a pain 
she begins to mumble fretfully, and as it reaches its height she 
concentrates all her voice into a peculiar frenzied cry, so charac- 
teristic of labor that one who has ever heard it would recognize 
it at once, even amid the most improbable surroundings. 

With it all, however, the woman does not complain as much 
now as during the first stage, and, instead of plying the nurse 
and physician with impatient demands for relief, she devotes her 
entire energy to delivering herself, and at times seems almost 
oblivious of her surroundings. 

Towards the end of the second stage, when the head is well 
down in the vagina, its pressure often causes small particles of 
fecal matter to be expelled from the rectum at the occurrence of 
every pain. This must receive most careful attention in order to 
avoid infection. 

The pains are now occurring so rapidly that there is scarcely 




Fig. 33. — Preserving the perineum. 




Fig. 34. — Another case. Preserving the perineum. 




-The same case. Farther advanced. It is becoming necessary to use the full hand 
in retarding the progress of the head. 




Fig. 36. — The same case again. Emergence of the forehead and face. No perineal tear 

visible as yet. 




Fig. 37- — The same case continued. Delivery of the anterior shoulder. Note the congestion 

of the child's face. 




Fig. 38. — Expressing the placenta by the method of Crede. 




Fig. 39. — Twisting the membrane into the form of a rope to prevent tearing. 



• "*■■% ■ 







m 




Fig. 40. — Inspecting the placenta. 



STAGES OF LABOR. 79 

any interval between them, and finally, with a sharp, agonized 
shriek, the head is born and the mother lies gasping for breath 
and sighing contentedly. One or two more pains are enough to 
effect the birth of the body, and practically all of the labor 
is over. 

The Phenomena of the Third Stage. — Towards the end 
of the second stage the placenta has become detached from the 
uterine wall and lies loosely in the womb or partly in the vagina. 
After the birth of the child the uterus contracts firmly on the 
placenta, and there is a period of from ten to thirty minutes in 
which no pains occur and the exhausted muscles rest from their 
exertions. A little blood trickles from the vagina, and finally, 
with one short and not very severe pain, the placenta and mem- 
branes are expelled and the uterus contracts firmly and per- 
manently. 

The total duration of labor in normal cases averages 
about ten hours, the greater part of which time is taken up by 
the first stage; but the time may vary from one or two to even 
twenty- four hours without being in any way injurious to the 
patient. 



VIII 

The Physiology of the Puerperium 

The puerperium, also called the "puerperal state" and the 
" lying-in state," is practically a period of convalescence extend- 
ing from the end of the third stage of labor to the time when 
the patient has fully recovered from its effects. While, in nor- 
mal cases, it cannot properly be called a pathological condition, 
it is so nearly on the border line between health and disease that 
it must be most carefully watched lest serious complications 
develop suddenly and unexpectedly. 

Immediately after labor the patient experiences a sense of 
exhaustion, which is soon followed by a feeling of delightful 
comfort and repose. Her child is born, her sufferings have 
ceased, and she usually passes from a state of perfect content- 
ment into drowsiness, and finally into sound and natural sleep. 

Every effort should be made to encourage this state of affairs, 
and the necessary toilet of the patient and arrangement of the 
room must be made as quietly and expeditiously as possible, 
while all visitors, except possibly the husband or mother, are 
to be rigidly excluded. 

A chill occurring immediately after labor, and due partly 
to a disturbance of equilibrium between external and internal 
temperature, caused by the excessive perspiration in the stage 
of greatest muscular exertion, and partly to the sudden removal 
of a large mass of tissue from the abdominal cavity, is not of 
infrequent occurrence and has no unfavorable significance. A 
warm bed, hot-water bottles, and a drink of warm tea are all 
that is needed to control it effectually. 

The pulse of the puerperal woman should show a marked 
drop in frequency, due probably to greatly lessened arterial ten- 
sion. It usually goes down to about 60, and even a fall to 40 
beats per minute is not uncommon. This is always a favorable 
symptom, while a rapid pulse after labor is to be regarded with 
80 



PULSE AND TEMPERATURE. 8l 

suspicion as an indication of shock or possibly of concealed 
hemorrhage. 

The temperature of the patient usually rises slightly, and 
while 1 00.5 ° F. is generally regarded as the limit in normal 
cases, patients occasionally show a somewhat higher tempera- 
ture without ill effects. In judging of the significance of the 
temperature the pulse is the best guide, for a puerperal pa- 
tient with a slow pulse is not likely to do badly even if her tem- 
perature is a little high. Nevertheless, the nurse should report 
at once to the physician a temperature of over 100.5 ° F. or a 
pulse of over 100, and such a patient must be watched most 
carefully for the possible development of further unfavorable 
symptoms. 

The uterus begins to return to its normal condition with the 
beginning of labor. This process is called "involution/' and 
consists partly in the contraction of the womb and partly in the 
destruction of certain of its tissues, which are carried away not 
only in the discharge of blood and serum that follows later, but 
by means of the general circulation as well. The normal process 
of involution requires about six weeks, and at the end of that 
time the uterus should be, as nearly as it ever will be, in the 
condition it was in before pregnancy occurred. It never re- 
turns to exactly the virgin state, but may approach it very closely 
if there have been no lacerations of the cervix. 

Involution is favored and hastened by everything that tends 
to make the puerperium perfectly normal, and is delayed by 
the opposite condition. It is on this account that breast-feeding 
of the infant is urged in the interest of the mother, for the reflex 
connection between the breasts and the uterus is so well estab- 
lished that the irritation of the nipple in nursing acts as a power- 
ful stimulus to uterine contractions. 

"Subinvolution" is the term used to describe the condition 
which exists when involution is not complete at the time when 
it should be. It is a chronic condition, characterized by a large 
and flabby uterus usually more or less chronically congested, 
and causes the patient much discomfort and disturbance of 
health until it is corrected. 
6 



82 A NURSE'S HANDBOOK OF OBSTETRICS. 

The vaginal walls, the vulva, and all other tissues that have 
become hypertrophied during pregnancy also undergo a process 
of involution in their return to their normal condition, and the 
abrasions and lacerations of the genital canal caused by the 
passage of the foetus heal completely during the puerperium. 

Lochia is the name given to the discharges that come from 
the uterus and vagina for about three weeks after the birth of 
the child. At first the discharge consists almost entirely of blood, 
which escapes from the placental site on the uterine wall, mixed 
with a small amount of mucus and particles of decidua. This 
should not have large clots or membrane or be in excessive 
amount. It is known as " lochia rubra " (red lochia), or " lochia 
cruenta," and lasts about three days, when it gradually changes 
to a pinkish color due to the admixture of a considerable 
amount of serum from the healing surfaces ; it is known as 
" lochia sanguinolenta." Towards the eighth or ninth day the 
lochia is thinner, less in amount, and of a greenish-yellow color 
with characteristic odor, and is known as " lochia purulenta "; 
by the end of the third week the discharge usually disappears. 

The lochia should never, at any time, have an offensive odor, 
although it possesses a peculiar animal emanation which is quite 
characteristic. 

Premature suppression of the lochial discharge may be 
caused by cold, fright, grief, or other emotion, and is usually 
dependent upon a relaxed condition of the uterus. 

Late return of blood in the discharge, after it has once dis- 
appeared, often occurs when the patient gets up too soon, and 
is not of any serious import if she returns to her bed for a few 
days longer. But anything abnormal passed must be promptly 
reported to the physician and also saved for his inspection. 

" After-pains" are painful contractions of the womb occur- 
ring after labor and due to its efforts to expel a blood-clot which 
has formed within it when it was in a state of relaxation. After- 
pains are more common in women whose tissues are soft and 
flabby, and so are seen less frequently in primiparae than in those 
who have borne many children. They occur at intervals, like 
labor-pains, and often are said by the patient to cause her more 
suffering than the labor-pains themselves. The proper manage- 



RETENTION OF URINE. 83 

ment of the fundus uteri will insure firm and permanent con- 
traction, and is the best preventive against after-pains. When 
they are at all severe they interfere markedly with the patient's 
rest and comfort, and the physician will usually find it necessary 
to remove the clot from the uterus to effect a cure. Under or- 
dinary circumstances they will disappear spontaneously about 
the fourth day. 

Retention of urine is not uncommon during the first two or 
three days after labor, owing to the swollen condition of the 
urethra and the tissues surrounding it. Its treatment is dis- 
cussed in the following chapter. 

Constipation after labor is the rule rather than the excep- 
tion, because of the relaxed condition of the intestinal and 
abdominal muscles and the inability of many persons to empty 
the bowels while in the dorsal position on the bed-pan. As 
the rectum has been, or should have been, emptied by enema 
at the beginning of labor, nothing further is needed until about 
two days have elapsed, when the physician usually orders a 
simple cathartic, such as castor oil. 

The appetite of the patient is usually somewhat diminished 
during the early part of the puerperium, and this, combined 
with the fact that all of her excretions are markedly increased, 
causes her to lose flesh to the amount of from nine to twelve 
pounds before she begins to gain in weight. 

"Milk fever" is a term occasionally, and incorrectly, 
used to describe a slight and unimportant rise of temperature 
that occurs about the third day and subsides in a few hours. 
This was long supposed to be due to the development of milk in 
the breasts, which occurs at the same time, but it is now known 
to depend entirely on a very slight infection due to the un- 
avoidable introduction of a few bacteria into the genital tract. 
The author believes, however, that the mere discomfort, due to 
tension in the early days of lactation, unless steps are promptly 
taken to relieve it, is not infrequently responsible for this phe- 
nomenon, independently of any infection whatever. It is quite 
a regular occurrence, and should never last more than a day. 

Directions for nursing and care of the breasts will be 
found in another chapter. 



IX 

The Signs and Symptoms of Pregnancy 

As stated in the introductory chapter, it is highly desirable 
for the pregnant woman to be under medical care from as early 
a date as possible, and as women who suspect that they are 
pregnant are very apt to discuss the matter with a nurse before 
consulting a physician, the first duty of the nurse under such 
circumstances is to advise the patient of the importance of 
seeking medical counsel at once. 

More than half the women who present themselves at the 
physician's office late in pregnancy have nurses engaged for 
their confinements, and yet it seldom happens that these patients 
visit the physician by the direction of their nurses. In short, 
it would seem that nurses and physicians do not work together 
in such matters to the extent that they should, and it rests with 
the nurses to bring about a more harmonious state of affairs. 

Naturally, before advising a patient to consult a physician 
in regard to a suspected pregnancy, the nurse will wish to be 
reasonably sure in her own mind that conception has actually 
occurred. 

There are many signs and symptoms which point to the 
existence of pregnancy, some of which can readily be recog- 
nized by the nurse, while others can only be made out accurately 
by one who has had a thorough medical training. 

Of these signs, but three are absolutely indicative of preg- 
nancy, and of these, two may be absent if the foetus has died 
in the womb. Moreover, these " positive" signs are not present 
until about the middle of gestation, when the physician can 
usually make a diagnosis without them by the " circumstantial 
evidence" of a combination of earlier and less significant symp- 
toms. 

While, in the great majority of cases, the early diagnosis of 
pregnancy is extremely easy to one familiar with such condi- 
84 



MORNING SICKNESS. 85 

tions, it occasionally presents many difficulties, even to the 
skilled observer, and in rare instances no positive statement 
can be made until one or another of the three positive signs has 
appeared. 

The signs of pregnancy are divided by most writers into 
three groups, and in the following table those which are appre- 
ciable to the educated nurse are printed in heavy-faced type. 

A. PRESUMPTIVE SIGNS. 

1. Menstrual Suppression. 

2. Vomiting. (" Morning Sickness.") 

3. Irritability of the Bladder. 

4. Mental and Emotional Phenomena. ("Morbid 

Longings, etc.") 

B. PROBABLE SIGNS. 

i. Mammary Changes. (Enlargement of the 
Breasts, Shooting Pains, Pigmentation, etc.) 

2. Bimanual Signs. (Size of Uterus, Hegar's Sign, etc.) 

3. Abdominal Changes. (Size, Shape, Pigmenta- 

tion, etc.) 

4. Changes in Cervix. (Size, Shape, Consistency, etc.) 

5. Violet Color of the Vaginal Mucous Membrane. 

6. Uterine Murmur. 

7. Intermittent Uterine Contractions. 

C. POSITIVE SIGNS. 

i. Passive Fetal Movements. (" Ballottement.") 

2. Active Fetal Movements. ("Quickening.") 

3. Fetal Heart Sounds. 

Cessation of menstruation and morning vomiting are 
placed first in the list of Presumptive Signs because the former 
is the symptom usually first noticed by the patient and the latter 
is the one that is most likely to bring her to the physician. 

Irritability of the bladder, characterized by very frequent 
and often more or less painful voiding of the urine, is also apt 
to be the first symptom of pregnancy. This may occur very 



86 A NURSE'S HANDBOOK OF OBSTETRICS. 

shortly after conception and before the next menstrual period 
is due. and as it is often ascribed by the patient to " catching 
cold," or to some other trivial cause, it is not, as a rule, men- 
tioned except in response to the questioning of the physician. 
This irritability is due to the pressure, on the bladder, of the 
recently impregnated uterus, which has a tendency to tip for- 
ward and settle down deeply in the pelvis, and, when accom- 
panied or followed by stoppage of the menstrual flow it is, in 
a married woman, very suggestive of pregnancy. 

If this combination of symptoms is followed by vomiting on 
arising in the morning, or even by nausea at this time, the diag- 
nosis becomes more probable than ever. 

The usual character of this form of vomiting is that of a 
sudden, paroxysmal emptying of the stomach, occurring the 
moment the patient gets out of bed. Under normal conditions, 
it may continue until about noon, the stomach promptly reject- 
ing any food or drink that may be swallowed. After twelve 
or one o'clock the irritability of the stomach usually ceases, 
and the patient has no further trouble or discomfort until the 
next day, when the whole affair is repeated. This symptom 
begins, as a rule, about the end of the second month, but it 
may be noticed at any time after conception has occurred, even 
as early as the third or fourth day. It generally stops by the 
end of the fourth or fifth month, and vomiting occurring late 
in pregnancy is always to be regarded with suspicion, as indica- 
tive of some severe systemic disturbance of toxasmic origin. 

Mental and emotional phenomena are, fortunately, not 
very common, but they may be noticed in some cases. For 
example, a woman of the most amiable disposition may, under 
the influence of pregnancy, become exceedingly disagreeable and 
fretful, while, on the other hand, one of great asperity may, 
rarely, go to the opposite extreme and take on the qualities of a 
veritable saint. In the same way, articles of food and forms of 
amusement, ordinarily unthought of, may suddenly be demanded, 
and in rare instances the most unusual and even disgusting 
impulses may be fostered. The writer has had recently under 



CHANGES IN THE BREAST. 



87 



his care a woman who, when pregnant, developed an irresistible 
appetite for raw potatoes. 

The changes in the breast include enlargement of the 
entire gland on both sides ; a sense of fulness, and shooting or 
tingling pains in these organs ; and darkening of the tissues 
surrounding the nipples (Fig. 41). Temporary slight enlarge- 




FlG. 



Marked pigmentation of breast. Tubercles of Montgomery and a drop of milk 
on the nipple plainly shown. 



ment of the breasts and sensations of weight and fulness are, of 
themselves, of no significance, for, in many women they may be 
noticed at the ordinary menstrual periods, but the darkening of 
the areola around the nipples and the presence of a silvery white 
fluid (colostrum), which can be squeezed out of the breast, 
constitute, in a woman who has never borne children, very 
significant signs of pregnancy. If, however, the woman has 
had a child, the areolar pigmentation from the previous preg- 
nancy will remain, and it is not unusual for colostrum to be 
present for months or even years after it has once appeared. 
Thus, while it is apparent that these breast symptoms are not 
of much account in the case of a woman who has borne chil- 



88 A NURSE'S HANDBOOK OF OBSTETRICS. 

dren, they are of great significance if the patient has never been 
pregnant before. 

The abdominal changes are supposed to begin with a flat- 
tening of the abdominal wall in the early weeks of gestation, 
due to the tipping forward and sinking of the uterus, to which 
reference has already been made as causing irritability of the 
bladder. This supposititious flattening has given rise to the old 

French saying, — 

" Ventre plat, 
Enfant il y a ;" 

which doggerel, being translated freely and with equal poetic 
feeling, would read, — 

" In a belly that is flat 
There's a child, be sure of that;" 

but, as King has said, " One can't be sure of that," by any 
means. In the first place, the uterus at this time is so small 
that no change in its position would have any tendency to 
appreciably flatten or otherwise affect the contour of the ab- 
dominal wall, and even if such a change did occur it would be 
so slight that it is highly improbable that it would ever be 
noticed by the patient or brought to the attention of the physi- 
cian or nurse. 

The pigmentation of the abdomen, extending up the 
median line and surrounding the umbilicus is, in a woman 
who has never borne children, almost diagnostic of pregnancy, 
but, like the pigmentation of the breast, it varies exceedingly in 
different subjects, being often entirely absent in decided blondes 
and exceptionally well marked in pronounced brunettes. In 
women who have borne children previously this pigmentation 
remains from the former pregnancies, and cannot be depended 
upon as a diagnostic sign. 

The size of the abdomen in pregnancy corresponds with 
the increase in the size of the uterus, which, at the end of the 
third month is at the level of the symphysis pubis, at the end of 
the sixth month at the level of the umbilicus, and towards the 
end of the ninth month at the ensiform cartilage. Mere ab- 



PASSIVE FETAL MOVEMENTS. 89 

dominal enlargement may be due to a number of causes, such 
as an accumulation of fat in the abdominal wall, dropsy, 
uterine or ovarian tumors, and the like. If, however, the uterus 



Fig. 42. — Size of the uterus at each month of pregnancy. The fundus reaches the 
symphysis at the third month, the umbilicus at the sixth month, and the ensiform cartilage 
at the middle of the eighLh month, after which it sinks a little before labor begins. 

can be distinctly felt to have enlarged in the proportions stated 
above, pregnancy may properly be suspected. The nurse cannot 
be expected to make out this uterine enlargement until the fundus 
is well above the symphysis, so this sign is of no value to her as 
a means of early diagnosis. 

The nurse will hardly be called upon to inspect the vaginal 
mucous membrane for evidences of pregnancy, but it may be 
said that, owing to pressure and consequent congestion within 
the pelvis, this mucosa becomes thickened and of a dark violet 
or purple color instead of its customary pinkish tint in the non- 
pregnant state. This sign is of no special value in women who 
have borne children, and as it may be due to any form of con- 
gestion or to the presence of new growths or varicosities within 
the pelvis, it is very unsatisfactory at best. 

Passive fetal movements (" ballottement," from the 
French ballotter, to toss up like a ball) can only be made out 
by the physician skilled in obstetric examinations, but the 
active movements of the fcetus within the uterus are readily 



9° A NURSE'S HANDBOOK OF OBSTETRICS. 

recognized after the fifth month by placing the hand firmly 
against the abdominal wall over the uterus and holding it there 
until the foetus is felt to kick vigorously, as it does every few 
minutes. This sign is unmistakable to the examiner, although 
the patient may sometimes imagine the movements of gases in 
the intestines to be the motions of a foetus within the uterus. 
If the child is dead these movements will not be felt, but there 
will usually be a history of the previous occurrence of such fetal 
activity. 

The sounds of the fetal heart are often heard with great 
difficulty by the physician, and it is not to be expected that a 
nurse will always be able to make them out. Occasionally, 
however, in the latter months of pregnancy and with all con- 
ditions favorable, the nurse will be able to hear the fetal heart- 
beat, like the ticking of a watch under a pillow, by placing the 
ear firmly against the abdominal wall. 

The fetal heart should make from one hundred and thirty 
to one hundred and fifty beats to the minute, and is absolutely 
distinct from the maternal pulse. Like active fetal movements, 
this sign will not be discovered if the child is dead. 

Having decided, from one or more of the above signs, that 
the woman is probably pregnant, or if there is any doubt as 
to her condition, she should be directed to consult, at once, the 
physician who is to attend her during her confinement. 

The probable date of the labor may be computed by 
taking the first day of the last menstruation, counting back three 
months, and adding seven days. This will give a date which 
is to be regarded as the middle of a period of two weeks during 
which the labor may be expected to occur. Thus, if the woman's 
last menstruation began on June 14, count back three months 
to March 14 and add seven days, making March 21. She may 
then be told that her labor will probably take place between 
March 14 and March 28. Remember that this is merely an 
approximate date, for the exact time of impregnation can seldom 
be determined, and it is not at all certain that the woman will 
go her complete term of two hundred and eighty days after 
impregnation, even if that date were positively known — so the 
exact date for delivery can never be definitely known. 



X 

The Mechanism of Labor 

In studying the mechanical phenomena that accompany de- 
livery it is necessary to consider three factors, — the " passenger' 
(foetus) ; the "passages" (uterus, vagina, and vulva) ; and the 
forces of labor, which impel the " passenger" through the " pas- 
sages" into the world. The forces of labor may be subdivided 
into two classes, — the expulsive forces, situated in the muscular 
fibres of the uterus and assisted by the powerful abdominal mus- 
cles ; and the resistant forces, which consist of the resistant 
powers of the tissues composing the cervix, the vaginal floor, and 
the perineum. 

These two classes of forces must be very nearly balanced, 
but with the expulsive force slightly in excess, if the labor is to 
be normal. If the resistant forces are in excess, labor cannot 
occur without operative interference, and if the expulsive force 
greatly exceeds the resistant force a precipitate labor will result, 
with probable severe laceration of the maternal soft parts and 
with great danger to both mother and child. 

The "passenger" (foetus) lies in the womb in a state of 
complete flexion, and we have to consider its presentation and 
its position, for unless these are both normal, or can be made 
normal, the labor cannot be normal. 

Presentation refers to that part of the foetus which " pre- 
sents" at the brim of the pelvis at the beginning of labor. For 
example, if the head lies in the brim ready to come down into 
the vagina the case is said to be one of " vertex" presentation ; 
while if the breech is first to appear, it is called " breech" pres- 
entation. 

Position has to do with the relation of the presenting part 
to the pelvis. Thus, in a vertex presentation, the back of the 
head (occiput) may point to the front or to the back of the 

9i 



A NURSE'S HANDBOOK OF OBSTETRICS. 




p IG ^ — Vertex presentation. (Bumm.) A, left occipito-anterior (L. O. A.); B, 
tight occipito-anterior (R. O. A.); C, right occipito-posterior (R. O. P.); D, left occipito- 
posterior (L. O. P.). 



VERTEX PRESENTATION. 93 

pelvis. The occiput never points exactly forward or backward 
in the median line, but is always directed to one side or the 
other of the middle. Consequently we may have any one of 
four positions in a vertex presentation, — namely : 

Occiput to left of front, or left occipito-anterior. (" L. 
O. A.") 

Occiput to right of front, or right occipito-anterior. (" R. 
O. A.") 

Occiput to right of back, or right occipito-posterior. (" R. 
O. P.") 

Occiput to left of back, or left occipito-posterior. (" L. 
O. P.") 

Vertex presentations (Fig. 43) occur in nearly all cases 
(ninety-seven per cent.), probably because the head is the 
heaviest part of the foetus, and so has a natural tendency to sink 
to the bottom of the uterus. The position of more than half 
(seventy per cent.) of all vertex presentations is with the occiput 
to the front and to the left of the median line. This is called 
the " left occipito-anterior" position of the vertex, and is usually 
abbreviated by physicians as " L. O. A.," an expression with 
which the nurse will become very familiar in the course of her 
obstetrical training. " L. O. A." is by far the most common of 
all positions, and as, for this reason, it may be regarded as the 
normal position of the foetus in utero it is also occasionally styled 
the " first" position. 

In the same way, the other positions of the vertex, " R. O. 
A.," " R. O. P.," and " L. O. P.," are sometimes called, respec- 
tively, the second, third, and fourth positions of the vertex. 

In order that the vertex, or top of the head, may present, the 
head must be "flexed;" that is, tipped forward on the chest; 
and this flexion increases as labor progresses until the head has 
passed through the brim of the pelvis and is in the vagina 
(Fig. 44). 

While the head is descending in this way the occiput is grad- 
ually rotated forward (in anterior cases) until it lies in the 
median line in front and under the symphysis pubis. This rota- 
tion is due to the action of the funnel-shaped walls or "inclined 



94 



A NURSE'S HANDBOOK OF OBSTETRICS. 



planes" of the pelvis, which turn the head in the right direction 
much as a ball may be rolled down a winding gutter or trough. 



Fig. 44. — Flexion of head during second stage. (Pinard and Varnier.) The shaded 
head shows the minor flexion at the beginning of labor, and the unshaded the stronger 
flexion as labor progresses, oc, oc', occiput. 



As soon as the completely flexed head has passed through 
the pelvic brim and lies with the occiput under the symphysis, 
the process of " extension" begins. The chin is now raised from 
the infant's chest and sweeps down over the posterior vaginal 
wall and perineum into the world ( Fig. 45 ) . The occiput, which 
has been practically stationary under the symphysis, where it has 
acted as a pivot during the extension of the head, is now born, 
and the most difficult part of the labor is over. 

Almost immediately after the birth of the head it is again 
rotated in a quarter-circle, so that its back points to the same 
side that it did at the beginning of labor. This is called " exter- 
nal rotation'' or "restitution" (Fig. 46), and is caused by the 
action of the inclined planes of the pelvis on the shoulders of 
the infant, which are rotated like the head as they pass down 
through the pelvic canal. " External rotation" is of interest 
to the physician, as it enables him to verify his diagnosis of posi- 
tion, made at the beginning of labor. If the case is " L. O. A.," 



FLEXION AND EXTENSION. 



95 



the back of the head will, after external rotation, point to the 
left side of the mother, as it did before labor began. 




Fig. 45. — Extension of the head in anterior presentations of the vertex. (Garrigues.) 

We have, then, to consider during labor in anterior positions 
of the vertex (" L. O. A." and " R. O. A."), Flexion, Rotation, 
Extension, and Restitution of the head, all accompanied by De- 
scent (Fig. 47). 

If, instead of being Hexed, the head, in a vertex case, is ex- 
tended or tipped backward on the body of the child at the begin- 
ning of labor, the case will become one of "face" presentation. 
This is one of the most serious complications that can arise in 
connection with labor, for if the face cannot be changed by the 
physician into a vertex presentation, the child cannot be born, 
except in rare instances, without operative interference of one 
kind or another (Fig. 48). 



9 6 



A NURSE'S HANDBOOK OF OBSTETRICS. 



"Brott/' presentations are those midway between face and 
vertex, and occur when the head is neither fully flexed nor fully 




Fig. 46. — External rotation. (Garrigues.) The case was originally L. O. A., and the vertex 
now points to the left thigh of the mother. 

extended (Fig. 49). Because of the ''wobbly" position of the 
head, brow cases usually convert themselves into either face or 
vertex presentations before labor is very far advanced. Hap- 
pily, the most common outcome of a brow case is spontaneous 
conversion into a vertex presentation. 

Either a brow or face presentation may occur in any one of 
four positions, named according to the direction in which the 
chin points (Fig. 50). 

Breech presentations are those in which the breech instead 
of the vertex presents at the pelvic brim. They are fairly com- 



INTERNAL ROTATION AND EXTENSION. 



97 



mon, and the chief difficulty in their management lies in the 
fact that, during the descent of the body, the arms of the fcetus 
are liable to become extended above the head and interfere 




Fig. 47- — Internal rotation and extension. (Tarnier and Chantreuil.) 

seriously with its passage through the pelvis (see Fig. 64). 
Breech presentations occur in any one of four positions, named 
according to the direction in which the sacrum of the infant 
points (Fig. 51), thus: 

Left sacro-anterior (" L. S. A.") 

Right sacro-anterior (" R. S. A.") 

Right sacro-posterior ("R. S. P.") 

Left sacro-posterior (" L. S. P.") 

In breech cases the infant often passes meconium from its 
rectum during the course of the labor, and if, after the mem- 
branes are ruptured and the liquor amnii has escaped, the nurse 
finds a black, tarry discharge coming from the patient's vagina, 
she may very properly suppose that the case is one of breech 
presentation. 
7 



98 



A NURSE'S HANDBOOK OF OBSTETRICS. 





Fig. 48. — Shape of head of child 
born in face presentation. (Char- 
pentier.) 



Pig. 49. — Shape of head ot 
child born in brow presentation. 
(Charpentier.) 




Fig. 50. — Face presentation. (Bumm.) 



BREECH PRESENTATION. 
A B 



99 





Fig. si—Breech presentation. (Bumm.) A left sacro-anterior; B right sacro-posteno. 




Fig. 52.-Prolapse of arm in transverse presentation. (Tarnier and Chantreuil.] 



IOO A NURSE'S HANDBOOK OF OBSTETRICS. 

Other presentations, all of which are very rare, are those of 
the foot, arm (Fig 52), or shoulder. 

The study of the special mechanism of the different presenta- 
tions and positions is one of great interest, but the brief outline 
given of the mechanism in anterior positions of the occiput is 
all that directly concerns the nurse. All other cases are more or 
less abnormal, and, as their progress is usually slow, their manage- 
ment must be left entirely in the hands of the medical attendant. 

OBSTETRICAL DIAGNOSIS 

This is made in five ways : ( 1 ) Inspection ; (2) palpation 5(3) 
vaginal examination; (4) auscultation; (5) pelvimetry. 

Nurses are expected to know whether a presentation is normal 





Fig. 53. — Usual method of palpating the abdomen. The palms of hands are used. 

or otherwise, as the work in rural, sparsely settled localities may 
often require of her knowledge not demanded in her hospital 
training. Only under most unusual conditions would she be ex- 
pected to do this in any other way than by inspection and pal- 
pation, and with this she should thoroughly familiarize herself. 
For palpation she lays both hands, gently always, flat upon 
the abdomen (Fig. 53). If done in any other manner than this 
the stimulation of her fingers will cause the abdominal muscles 



OBSTETRICAL DIAGNOSIS. IOI 

to contract. She can (excluding all other possible findings) so 
palpate the uterus in a definite routine way as to decide the pres- 
entation and position of the foetus. 

1. She should ascertain what is lying at the fundus of the 
uterus by feeling with both hands — generally a little to the left 
or in the median line will be felt one pole of the foetus. She must 
decide which pole it is by observing three points : 

(a) Its relative consistency. The head is harder than the 
breech. If the placenta lies between the head and the hand — this 
cannot be determined, however, in this way. 

(b) Its shape. If the head, it will be round and hard and the 
transverse groove of the neck may be felt. The breech has no 
groove ; and sometimes the feet may be felt. 

(c) Its mobility. The head will move from the neck. The 
breech only with the trunk. 

2. She should feel for the back of the foetus with both hands, 
pressing the uterus between the hands at about the level of the 
umbilicus. She will either feel : — 

(a) The firm back or the irregular outline of the limbs. She 
will know, if the back lies in the long axis of the uterus, that the 
head or breech presents. If the back lies horizontally or obliquely 
across the uterus, the presentation is, of course, transverse. 

3. She will feel if the pelvic brim is empty or ascertain what 
part presents by means of pelvic palpation, known as Pawlik's 
grip. It consists in placing the fingers over the centre of Pou- 
part's ligament on the left side and the thumb on the right cor- 
responding spot and by pressing together feel either the head or 
breech as she did when palpating the fundus. 

Thus she will feel : 

1. The head or breech at the fundus. 

2. The back or limbs at the level of the umbilicus. 

3. She may find the back of the foetus horizontally or obliquely 
across the uterus. 

This position must be remedied by an operation known as 
version. Owing to the fact that any position in which the child's 
long axis does not correspond to the long axis of the mother is 
a serious condition and will be fatal to one or both lives, it is im- 
portant that it be discovered as early as possible. 



XI 

The Management of Pregnancy 

When the pregnant woman consults the physician in refer- 
ence to her condition, he will first determine the duration of the 
gestation and the probable date of the expected labor, and then 
give the patient some general hygienic rules for her guidance 
during her pregnancy. 

It is not only proper, but important, for the nurse to have a 
clear understanding of the nature of these directions: 

Clothing. — Corsets and any other garments that constrict 
or compress the chest, waist, or abdomen must be laid aside from 
the first, and the skirts supported from the shoulders by means 
of some form of "corset- waist." There are a number of ma- 
ternity corsets on the market, the best known being the Jenness- 
Miller and the Ferris Maternity or Berthe May corset. 

The reasons for this rule are many and important. In the 
first place, anything that compresses the chest retards greatly the 
development of the breasts, which should be marked during preg- 
nancy, and by so doing tends to flattening or even depression of 
the nipples. Both of these conditions will interfere with the 
function of lactation, even if they do not render it entirely impos- 
sible ; and as the proper performance of nursing has a direct and 
powerful effect on the involution of the uterus and its return to 
its normal condition after labor, any such interference exerts a 
most unfavorable influence on the convalescence of the mother 
as well as upon the health of the infant thus deprived of its 
natural form of nourishment. 

Moreover, pressure on the chest walls, especially as- it is in- 
creased from day to day by the gradual enlargement of the 
breasts without any compensating loosening of the corsets, pre- 
vents necessary expansion of the lungs and hinders the working 
of the heart, already hypertrophied as a normal result of preg- 
nancy. The harmful consequences of such conditions can readily 
be seen, for it is not difficult to understand that a woman who 
has to supply oxygen for herself and another being, and who 

102 



WEARING APPAREL. 



103 




must eliminate, with her own blood, the waste products of an 
unborn infant as well as those of her own body, must neces- 
sarily have her respiratory and circulatory organs unhampered 
if she is to perform these tasks in a thoroughly normal way. 

The injurious results of pressure about the zvaist and ab- 
domen are much the same. Respiration is affected by interfer- 
ence with the play of the abdominal muscles and the diaphragm; 
circulation is impeded by pressure on the large abdominal blood- 
vessels; the normal action of the 
kidneys, liver, and digestive or- 
gans is seriously hampered ; and, 
lastly, the full development of 
the infant is markedly interfered 
with. 

The use of -corsets and the 
practice of " lacing " during preg- 
nancy are usually due to a desire 
on the part of the mother to con- 
ceal her condition as long as pos- 
sible, coupled with ignorance of 
the disastrous results that may, and often do, follow the em- 
ployment of such means of concealment. 

Most women will abandon these devices at once when their 
dangers have been carefully explained. 

Loosely fitting garments do more to conceal the progressive 
abdominal enlargement of pregnancy than can be accomplished 
by lacing or other mode of constricting the figure. 

If for any reason a maternity corset is not desired, comfort 
for the pendulous breasts and abdomen may be secured by wear- 
ing a maternity binder. This affords relief from the weight and 
movements of the child. Instead of the breast supporter a well- 
fitting brassiere, if properly adjusted, will serve the purpose 
equally well. But these supports must be perfectly fitted to the 
constantly enlarging figure. 

Undergarments should be made of wool, of a weight suited 
to the season of the year, and should extend down to the ankles 
and cover the arms to the wrists. 



Fig. 54- 



Abdominal binder. To be worn 
during pregnancy. 



104 A NURSE'S HANDBOOK OF OBSTETRICS. 

Wool is insisted upon, to the exclusion of cotton or linen, 
because it absorbs perspiration as rapidly as it is excreted, and 
so keeps the skin dry at all times. When the integument is damp 
with perspiration, as it is in hot weather or after exertion, if 
cotton or linen underwear is worn, any sudden chilling of the sur- 
face will close the capillaries and drive a considerable amount of 
blood to the interior of the body, causing congestion of the in- 
ternal organs. At the same time, this chilling of the surface and 
contraction of the capillaries prevent further perspiration, and 
so throw an additional strain on the kidneys, now congested 
through increased blood-supply and overworked by the addition 
of fetal to the maternal elimination. 

Outer garments are to fit loosely, and must be enlarged as 
occasion requires. There are on the market a wide selection in 
all varieties of goods and patterns, the principle upon which they 
are built being the avoidance of all constriction to breasts and 
abdomen, and the hanging of all weight upon the shoulders. 

Garters that encircle the leg tend to the development of vari- 
cose veins in the lower extremities, and are to be discarded in 
favor of some form of stocking supporters attached to the corset- 
waist or extending over the shoulders. It will be remembered 
that arteries have muscular tissue in their walls, while veins have 
little or none, and that arteries stand open when empty, while 
veins collapse. Hence any constriction of an extremity affects 
the vein far more than the arteries, and blood, which meets 
with no obstruction whatever in its flow down the extremity 
through an artery, will, on its return through the vein, find at 
the point of constriction sufficient closure of the vessel to dam 
it back and so stretch the vein wall that a varicosity is formed. 
As there is already a marked tendency in this direction, by 
reason of the enlarged and constantly enlarging uterus imped- 
ing return circulation from the lower extremities by compres- 
sion of the great abdominal vessels, corsets or garters tend to 
aggravate the condition. Garters that encircle the leg should 
never be worn, even by unmarried women, for the tendency to 
varicosities is always present, and when once formed they never 
disappear but grow worse from year to year. 



WEARING APPAREL. 105 

Shoes. — Comfortable, well-fitting shoes are the only foot cov- 
ering to be considered during pregnancy. High heels interfere 
with a proper poise of the body and throw weight upon the 
lower abdomen in addition to the strain caused by the growing 
uterus. The shoes may have to be worn a larger size because 
of the tendency of the feet to swell. If walking is to be a 
pleasure and not a pain, proper shoes must be worn. 

Exercise in the open air should be taken daily throughout 
the entire course of pregnancy, and, of all forms of exercise, 
walking is, without question, the best. Smooth roads are to 
be selected for the daily jaunts, and they must be so regulated 
as to distance that the woman will arrive home exhilarated, 
but just within the point of fatigue. 

A woman of ordinarily good physique, beginning her walks 
early in pregnancy, should start with about one mile and in- 
crease the distance half a mile a day until six miles are covered. 
When this distance is reached it is to be regarded as the regular 
daily task if it can be accomplished comfortably, but if it prove 
to be exhausting it must be cut down to a more suitable length. 

While six miles a day is not too much for a strong healthy 
woman accustomed to out-door life, and may safely be taken 
as a standard for comparison, it must never be forgotten that 
many patients of frailer constitution can be allowed only two 
or three miles a day, and no woman should ever be urged to 
undertake more than her strength will permit. 

The final test lies in the condition in zvhich the patient re- 
turns home. If she is tired and worn out, the distance has been 
too great, while if she is invigorated and refreshed at the end 
of her walk, it has been beneficial. 

Moderately stormy days need not interfere with the usual 
outing if the woman is properly dressed for the weather, with 
rain coat, high storm boots, and rubbers or overshoes. The 
dangers of chilling the body, and consequent congestion of the 
internal organs, must always be kept in mind, and if, by any 
accident, a pregnant woman is inadvertently exposed to in- 
clement weather and returns home cold and exhausted, steps 
must be taken at once to stimulate surface circulation and 
restore warmth to the body. 



106 A NURSE'S HANDBOOK OF OBSTETRICS. 

A hot drink of milk or tea should be given, and then, after all 
clothing has been removed, the patient is to be rubbed vigorously, 
wrapped in warm blankets, and surrounded with external heat. 

As soon as she is perfectly comfortable and entirely free 
from all chilly sensations, the blankets are removed and she is 
again rubbed briskly with warm, diluted alcohol and dressed 
in warm clothing, unless she prefers to remain in bed between 
sheets. She is to lie in the blankets only long enough to get thor- 
oughly warm and not until she begins to perspire. 

Walking is preferred during pregnancy to every other form 
of exercise, because it stimulates the muscular activity of the 
entire body, and in the later months it distinctly favors the des- 
cent of the fetal head into the pelvis, insures complete flexion, 
and shortens materially the first stage of labor. Moreover, it is 
available to all women, no matter what their circumstances in 
life may be. 

Aside from walking there are very few forms of out-door 
exercise that meet the requirements of the pregnant woman. 
Dancing and horseback riding are too violent and driving not 
sufficiently invigorating; tennis is too uneven and tiresome, and 
croquet too tame and uninteresting; while golf in moderation 
and automobiling over smooth roads are debatable questions, 
and may possibly be permitted, especially if the latter is una- 
voidable. But a continuous motion may induce the onset of 
premature labor. Walking is the best of all, and if any of the 
other permissible forms are allowed it should be only at rare 
intervals and on special occasions. 

Of in-door exercise there is only one form worthy of con- 
sideration. Massage combined with passive movements is some- 
times most helpful where the oedema interferes with the blood 
circulation. (Massage of the breasts and abdomen must of 
course be carefully avoided.) This consists in stimulating the 
abdominal muscles by lying on the back on the bed or floor 
and, with the arms folded over the chest or the hands clasped 
back of the head, rising to a sitting posture without drawing up 
the legs or raising the heels. This is to be repeated several 
times until a slight sense of fatigue is experienced, and should 



IN-DOOR EXERCISE. ioj 

be begun early in pregnancy and practised twice daily, in the 
morning before arising and at night just before retiring. 

If this form of exercising the abdominal muscles is found to 
be too difficult, as is often the case, the patient may, instead, lie 
on her back and raise the feet slowly in the air, first one foot at 
a time and then both feet together. This should only be done 
by order of the obstetrician and never on the patient's initiative. 

The sewing machine is a most potent factor in the causation 
of miscarriages and must be used to a very restricted degree, 
if at all. It is quite a simple matter to attach electric power to 
a sewing machine, so the objection to its use is much lessened. 
The lifting and carrying of heavy weights or a child, all un- 
necessary stair climbing, and every form of violent exertion must 
studiously be avoided. The patient should avoid crowds and all 
conditions affording her a sense of discomfort. 

Bathing at frequent, stated intervals is of the utmost im- 
portance, and baths should be taken daily when possible. Warm 
water and an abundance of soap are to be used, for it is essential 
to keep the skin in good condition and the pores free, lest per- 
spiration be interfered with and too great a strain be thrown 
upon the kidneys. 

The relation of perspiration to the action of the kidneys is 
little understood by the laity, and most persons are unaware that 
the skin of an adult excretes, in twenty-four hours, from one and 
one-half to two pints of fluid, or nearly as much as is eliminated in 
the form of urine, and that if perspiration were to cease entirely, 
the kidneys would be unable to perform the double task which 
would be required of them, and death would inevitably result 
within a few hours. 

Baths are best taken at night, just before retiring, and fol- 
lowed with a brisk rub, but a morning bath may be allowed, even 
with tepid or cool water (85 ° to 90 F.) if the patient has always 
been accustomed to one. Salt water " still " bathing is usually 
beneficial when practised under proper conditions, but bathing 
is distinctly contraindicated throughout the entire period of gesta- 
tion. As routine, cold baths, cold sponges, cold shower baths must 
all be prohibited. At the last month many physicians advise the 



108 A NURSE'S HANDBOOK OF OBSTETRICS. 

use of a shower bath or spray, or sponge of the proper tem- 
perature to avoid the possible entrance into the vagina of the 
water in a bath tub. This is logical and recommends itself. In 
addition it is often most difficult for the patient to get in and out 
of the ordinary bath tub unless she has help. 

Sleep, in greater amount than usual, is required by the preg- 
nant woman, and, in addition to the regular sleep at night, a nap 
of one or two hours in the afternoon is highly desirable. // the 
patient is unable to sleep in the daytime, the afternoon nap should 
not be entirely given up, but she should lie down on the bed or 
couch and rest quietly for an hour or two every day. 

The bedroom should be of good size on the south or east side 
and in a quiet part of the house, and thoroughly well ventilated. 
Even on the coldest winter nights a window can be opened a few 
inches at the top and bottom to insure a free circulation of fresh 
air. If the bed is, necessarily, so situated that it is in the direct 
line of draft, a screen may be placed at its side, or, if such 
a piece of furniture is not available, one may be improvised. 

The teeth of a pregnant woman are apt to undergo certain 
destructive changes, which have given rise to the old saying, 
" For every child, a tooth." This disorder is supposed to be 
due to increased acidity of the saliva, which is itself increased in 
amount, and it may result in caries of a rapidly progressing type. 
In addition, the gums may grow soft and spongy, and even bleed 
or become ulcerated. In rare instances there is a persistent 
toothache, not due to any lesion of the tooth or gums, but of reflex 
origin. As a precautionary measure, the woman should have her 
teeth examined and put in order by a competent dentist early in 
pregnancy, for painful or protracted dental operations performed 
during the period of gestation have been known to bring on mis- 
carriage. 

After the teeth have been thoroughly cleaned and any exist- 
ing cavities temporarily filled, further trouble can usually be 
averted by the frequent and systematic use of an alkaline mouth- 
wash. Phillips' " Milk of Magnesia " meets this indication per- 
fectly, and, after brushing the teeth, the mouth should be rinsed 



THE DIET. 109 

with a properly prepared solution before and after each meal, as 
well as after arising and before retiring. 

If the teeth have been properly put in order by a dentist in 
the early weeks of pregnancy, and if this after-care has been 
faithfully followed out by the patient, any pain or soreness of 
the teeth, mouth, or gums which does not subside promptly 
should be reported at once to the physician. 

The diet of the pregnant woman is to be carefully regulated, 
and only such articles of food are to be taken as will not over- 
tax the already hard-worked organs of elimination. 

This is a nice question about which there is much difference 
of opinion. The general popular idea is that a pregnant woman 
must be given a large amount of nourishing food, because " she 
must eat for two." It is now generally conceded that if her food 
is sufficient to properly nourish her body before she becomes 
pregnant, the same amount is all she requires while pregnant. 

Again, the popular idea still persists that the size of the child 
may be controlled by restricting the diet of the mother. This 
has not been incontrovertably demonstrated and the belief is 
seriously questioned. A fruit diet is supposed to make labor 
easier by a softening of the child's bones. This theory of bone 
salt seems to be disproved and the fruit in quantity is quite as 
much a bone salt diet as is the average three meals provided. 
In addition there is danger to the mother and a chance of rickets 
for the child. A special diet may be ordered by the doctor known 
as Prochownik's diet. It is quite simple, and can be procured 
by the most humble. The claim is made for it that, if systema- 
tically adhered to, the results will be perfectly normal, small in- 
fants. This theory has failed to meet with general acceptance. 

The proper diet for the pregnant woman is a simple, ordinary 
mixed diet. It must be carefully regulated to avoid throwing 
waste upon the kidneys, and foods which are difficult of digestion 
must not be taken. Among the latter are such articles as pastries, 
pickles, salads, pork, cabbage, and all articles fried in fat, whether 
meats or starches. Fruits, vegetables, cereals, buttermilk, cocoa, 
milk and its products with abundance of water, should be eaten 
in normal amounts. The one rule to follow at this time is to 



no A NURSE'S HANDBOOK OF OBSTETRICS. 

limit the use of meat and broths. Authorities seem to agree on 
meat but once a day. The occasional craving of pregnant wo- 
men for unusual articles of food must be kept in mind, and any 
desire of this kind may be granted with safety when the articles 
demanded agree perfectly with the patient and are not of too 
exceptional a nature. Any marked perversion of appetite should, 
of course, be reported promptly to the physician. Too much em- 
phasis cannot be laid upon the avoidance of alcoholic liquors. 
These are eventually depressants, though slightly stimulating at 
the time. Nervous muscular and secretive glands are all de- 
pressed. Investigation at different times indicates that the in- 
fluence of alcohol upon the germ plasm of male and female at 
time of conception and during pregnancy is to prevent the de- 
velopment of normal progeny. Never before has such un- 
mistakable warning been sounded against the danger of develop- 
ing a dependence upon alcohol as at the present time. Its ill 
effects are always definite, but during pregnancy the dangerous 
results are imminent and, unless specially ordered by a physician, 
alcohol is to be entirely omitted from the patient's diet. 

Some women seem to require more food than three meals a 
day. This may be supplied by eating fruit (such as oranges, 
apples, prunes or figs) upon rising and before retiring; a glass 
of milk with a cracker may be taken between meals. 

Eclamptic Toxaemia. — The exact cause of toxaemia during 
pregnancy is still a question ; and while many theories have been 
advanced in explanation of this phenomenon, none has been ac- 
cepted definitely by the entire medical- profession. 

One general statement may be made, however, and it a suffi- 
ciently safe working theory for the nurse to keep in mind and 
regard at all times as a correct explanation of the cause of 
eclamptic toxaemia. This is, that eclamptic convulsions are due 
to a storing up in the system of matter which should have been 
eliminated either by the kidneys, the liver, or the digestive tract. 
It will be remembered that the mother has to eliminate not only 
her own waste products, but those of her infant as well ; and that, 
at the same time, her organs of elimination are handicapped by 
pressure from the growing uterus and by the other disturbances 



THE BOWELS. Ill 

in the general working of the bodily functions that always accom- 
pany pregnancy. This pressure and the accompanying disorders 
of nutrition increase as pregnancy advances, and the danger of 
digestive disturbances grows greater from week to week. Even 
in the early months, when the pressure is slight and the functions 
of the emunctories have not been seriously affected, the diet must 
be carefully regulated to avoid a break-down when the strain is 
greatest. 

While many patients will conscientiously follow directions 
expressed in a general way only, certain women will pay no at- 
tention to anything but the most explicit rules, and with such 
unruly cases the diet-sheet given in the chapter on diets may be 
used to advantage. This list is, of course, only a general outline 
of the proper diet during gestation, for, as already stated, no 
absolute laws can be made to fit every case, and the likes and 
dislikes of the patient are never to be disregarded entirely. Food 
must be of such a character that the patient enjoys her meals 
thoroughly and gains regularly in weight and strength from day 
to day. 

Bowels. — The bowels of the pregnant woman are to be 
watched carefully, and at least one satisfactory evacuation should 
be secured daily. The functions of the bowels, kidneys, and skin 
are intimately connected, and neglect of any of these organs is 
a serious matter. Constipation will probably be encountered, as 
nearly all women are more or less constipated, owing largely to 
a lack of hygienic habits. This condition is aggravated during 
pregnancy and the serious consequences are proportionately in- 
creased. 

The attending physician will usually order just such measures 
for its relief as would apply to the condition if the woman were 
not pregnant. 

Personal habits of intelligent daily hygiene are the best vital 
resource a pregnant woman has, and, fortunately, the present- 
day tendency is very strongly to emphasize the preventive value 
of all these matters of exercise, sleep, diet, care of the skin, 
bowels and kidneys, beginning with the training of the infant 
and carrying the principle through life. The result, however, of 



112 A NURSE'S HANDBOOK OF OBSTETRICS. 

lack of proper habits must be combated as intelligently as pos- 
sible. 

Pregnant women are advised to live systematically, to eat 
proper foods, such as farinaceous foods, vegetables, and fruits. 
The patient should take two quarts of water daily; she should 
obey the faintest inclination to evacuate the bowels and adhere 
to a schedule, going to the closet at exactly the same hour each 
day. While there, she should be warm and undisturbed ; and 
she may find that much assistance may be derived from drink- 
ing a glass of hot water before breakfast. 

The doctor may order a soap suds enema, or injections of 
olive oil into the rectum at night to make a movement possible 
in the morning, or he may prefer drugs to the enemata, depend- 
ing upon the cause of the constipation. Usually cascara sagrada 
(Rhannus Purshiana) will be ordered at bed-time, in doses of 
from one-half to one teaspoonful, gradually increasing the 
amount. Glycyrrhiza Pulv. is sometimes effective. If the con- 
stipation is obstinate, it is well to administer a gentle saline 
laxative, such as the effervescent solution of citrate of magnesia 
or Seidlitz powder every third or fourth morning before break- 
fast. Castor oil or aloes must of course not be used. 

The mere mechanical effect of an overloaded bowel is to in- 
crease the pressure on the vital organs in a pelvis which is al- 
ready filled to its utmost capacity. The danger of absorption in 
the intestines from an accumulation of excrementitious matter 
in the system is very great. » 

Never employ massage for constipation if pregnancy exists. 

Diarrhoea is also a condition that cannot be safely neglected, 
for even if it is of simple origin and not due to any serious in- 
testinal disturbance, it may, if allowed to continue, be enough to 
undermine the patient's strength to a dangerous degree. Pro- 
longed or severe diarrhoea is often a direct cause of miscarriage 
as well, and any such condition of the intestinal tract which is 
not controlled promptly should be reported to the physician with- 
out delay. 

Kidneys. — Of all organs of the body perhaps none requires 
a larger degree of care during pregnancy than the kidneys. If 



THE BREASTS. 1 13 

at any time the amount of urine falls below normal, 50 ounces, 
an immediate report should be made. A specimen of urine is 
to be sent for examination every three weeks during pregnancy 
and once a week during the last two months. Where the patient 
has a previous history of symptoms suggesting toxaemia the doc- 
tor may order it sent more often. This specimen must be a sterile 
twenty-four-hour specimen of eight ounces, with complete sta- 
tistics as to amount passed in twenty-four hours, name, address 
and date. This is to be pasted upon the bottle to avoid possible 
mistake. The significance of many examinations is lost because 
of carelessness in this matter. The examination should be care- 
fully done and measures at once adopted to combat the findings 
of casts or albumin. This should be sent to reach the doctor in 
the forenoon, so that it may be examined the same day. Any 
cedema of the face, particularly the eyelids, the hands and feet, 
any headache or dizziness, must be instantly regarded and re- 
ported to the physician. 

Breasts. — These organs must always be protected from con- 
striction or pressure of any kind. The relief from weight has 
been suggested in the paragraph on clothing. They must be pre- 
pared for nursing by careful attention to the condition and de- 
velopment of the nipples, for, if the infant is unable to nurse, 
both it and its mother will suffer more or less. 

The effect of stimulation of the breasts, by suckling, on the 
involution of the uterus has already been mentioned, and it will 
readily be understood that the infant will thrive better on breast 
milk than on any other kind of food. 

The breast should be bathed night and morning with soap and 
warm water, to keep the skin in the best possible condition, and 
after the bathing they are to be sponged briskly with water as 
cold as the patient can bear, to stimulate the activity of the 
glandular tissue. 

The nipples, no matter how well developed and healthy they 
may be, are to be anointed every night with white vaseline or 
albolene, which is to be carefully removed in the morning with 
castile soap and warm water. This is to soften and remove the 
colostrum which the breasts secrete during the latter part of 

6 



H4 



A NURSE'S HANDBOOK OF OBSTETRICS. 



pregnancy, and which, if undisturbed, will form hard crusts 
on the nipples and excoriate the delicate tissues beneath. 

Nipples which are not treated in this way and upon which 
crusts of colostrum are allowed to remain are often extremely 
sensitive or even exquisitely painful when nursing is begun, and 
are especially liable to the formation of erosions or fissures which 
may prevent nursing entirely, either because of the suffering 
caused by the suckling or by the development of inflammation 
in the breast itself. 

If the nipples are small, flattened, or depressed, they should 
be drawn out with the forefinger and thumb and held for five 
minutes night and morning throughout the entire two months 
preceding the labor. This will often develop them to a surpris- 
ing degree, and nipples that at first seem absolutely unfitted for 
nursing can frequently be made sufficiently prominent by this 
treatment to meet the needs of the child perfectly. The patient 
can, of course, do this herself after the nurse has instructed her 
in the proper method ; but, as has been stated in a previous chap- 
ter, she must be cautioned as to the possibility of irritating the 
uterine muscle to contraction by too vigorous manipulation of 
the nipples, and warned to stop this treatment at once should 
any uncomfortable symptoms develop in the uterus or lower 
abdomen. 

If there are erosions, fissures, or other diseased condition of 
the nipples, the physician should be consulted, and he will pre- 
scribe appropriate treatment. 

Nervous Condition. — To the woman of the present day, 
freed as she is from much of the ignorance, superstition, and 
traditions of a generation ago, the period of pregnancy should be, 
if it proceeds normally, a period of much mental and physical 
quiet, comfort, and happiness. She should be spared every 
phase of physical and mental irritation possible. When ap- 
proached in the proper way, even children can be brought to co- 
operate and materially help in securing for the waiting mother a 
degree of calm, daily routine which will do much to prevent the 
development of abnormal nervous symptoms. 

The long waiting, with the hopes and fears accompanying her 



MATERNAL IMPRESSIONS. 1 15 

condition, may depress the patient, and the physical discomfort 
may irritate her; but these troubles can always be met by rest, 
good reading matter, and an interest in a larger world than her 
own condition. The care of a physician is her best anchor. 

She should not indulge in too much reading or in thinking 
of the physiological process of her condition. Here again her 
self-control will be the result of a life time of habit, and patholo- 
gical mental disturbances are exceedingly rare. 

The patient's fears occasionally gain control, and this calls 
for a tactful restraint over her more exaggerated moods. A 
welcome baby is apt to enjoy the blessing of a happy mother. 

Any deviation from a normal condition seeming to indicate 
excessive nervousness or melancholia must be promptly reported 
to the physician. 

As A GENERAL RULE FOR THE GUIDANCE OF THE NURSE in 

the management of pregnancy it is safest and wisest to report 
to the physician any condition that causes the patient special 
discomfort or that seems to be at all unusual. 

MATERNAL IMPRESSIONS AND THE CONTROL OF SEX 

By a maternal impression is understood an effect on the 
physical development of an unborn infant due to some shock, 
fright, accident, or other profound nervous strain sustained by 
the mother during the course of her pregnancy. 

The possibility of phenomena of this kind is believed by a 
great number of individuals, among whom may be counted many 
of the highest intelligence, and children are frequently seen 
with birth-marks, harelips, supernumerary fingers or toes, and 
other deformities and disfigurements of various types, all of 
which are attributed to some form of nervous impression from 
which the mother suffered during the period of gestation. 

It is safe to say, however, that the supposed connection be- 
tween these unfortunate occurrences and any mental state of the 
mother may be traced to coincidences, or to the imagination in 
every case, and the nurse should be informed on this subject in 
order that she may be able to reassure such expectant mothers, 
as may be apprehensive that their children will be " marked." 



Il6 A NURSE'S HANDBOOK OF OBSTETRICS. 

The effects of heredity must not be confused with the subject 
under discussion, and it must be borne in mind that certain traits 
and characteristics and certain diseases may be transmitted from 
the mother to her unborn child. Also, a mother who is in 
a markedly debilitated condition, or one who is given to excesses 
of any kind, such as the habitual use of alcohol, morphine, or 
other drugs, cannot be expected to give birth to a healthy, robust 
infant; and, for this reason, such a parent may be the mother of 
a deformed, disfigured, or partially developed child. 

Maternal impressions, however, are to be considered as sup- 
posedly affecting the physical development of the child as a 
result of a sudden profound shock transmitted entirely from 
without. 

While, perhaps, it cannot be said that this is an absolute im- 
possibility, it may be stated with the utmost positiveness that 
such an effect can occur no more easily before the birth of the 
infant than after it is in its mother's arms. 

It will be remembered that the ovum in which the fcetus de- 
velops is nothing more than an tgg of a peculiar kind, and that 
the child within it is, from the very first, an absolutely indepen- 
dent organism developing by itself, and not connected in any 
very intimate way with the mother. There is no mingling of 
the fetal and maternal blood-currents, and the blood of the fcetus 
merely gives up its waste products and takes in oxygen in the 
placenta as does that of the mother in her lungs. 

The placenta is merely a thickened area in the sac formed by 
the amnion and chorion, and the whole may be regarded as the 
shell (soft, to be sure) of the tgg in which the child is being 
formed. It is true that the placental structure penetrates to a 
certain depth into the tissues of the uterine walls, but it can no 
more be regarded as part of the maternal organism than can the 
roots of a tree be considered as part of the earth into which they 
extend. 

Moreover, the umbilical cord, which is the only direct at- 
tachment of the foetus to the placenta, is absolutely devoid of 
nerves, and no matter how much the placenta may be regarded 
as part of the mother, it is clear that there is no actual nerve 
connection between the two. 



MATERNAL IMPRESSION. 1 17 

In a word, the ovum, with its contained foetus, merely finds 
in the uterus a suitable nest for its development, and it is a fact 
that, except for the practical difficulties in the way, no mother 
is absolutely necessary to the development of her child after 
conception has occurred. If we could solve the practical prob- 
lem of transferring the fertilized ovum from the oviduct or uterus 
of one woman -to that of another, the process of development 
would go on just the same, much as a hen's tgg may be hatched 
by any hen or even in a purely mechanical incubator. 

That this statement is not idle speculation is proved by the 
fact that, in Edinburgh, two impregnated ova from a rabbit were 
transplanted to the oviduct of another rabbit of entirely dif- 
ferent breed, and this second rabbit eventually gave birth to two 
rabbits of the first variety, together with several others of her 
own kind. It should be said in explanation that both rabbits 
were impregnated at the same time by males of their own breeds, 
respectively, in order that the oviduct and uterus of the rabbit 
to whom the ova were to be transferred should be in exactly the 
necessary stage of gestational development. 

Thus it will be seen that the connection between a foetus and 
its mother is practically no more intimate before birth, while it 
lies in, and absorbs its nourishment from, her uterus, than after 
delivery, when it rests upon, and takes its nourishment from, her 
breast ; and that the opportunity for nerve impulses to pass from 
one to the other is equally impossible in either case. 

The question of the possibility of controlling the sex of unborn 
infants so that parents may beget male or female children at will 
has received much attention of late, and the nurse will often be 
interrogated in this connection. 

The most recent teaching goes to show that, for the present 
at least, this is a matter entirely beyond the power of the human 
mind. None of the many theories and methods that have been 
advanced from time to time has proved in any way reliable, and 
where results may seem to have been secured, the probability of 
coincidence must always be enough to overthrow any positive 
conclusions. 



XII 

Preparations for Labor 

THE PATIENT'S PREPARATION 

The average mother will need little argument to convince her 
that the early placing of herself under the observation and care 
of an obstetrician is her first duty to herself and child. She will 
desire to possess such accurate knowledge regarding the hygiene 
of pregnancy as will conserve the best interests of herself and 
children. Ignorance and disregard of scientific truths regarding 
the facts of life are often followed by tragedy. If she is wise 
she will concentrate her intelligence upon doing the obvious 
reasonable, and wholesome thing, in order to be as far as possible 
a poised, normal, healthy woman. Her doctor's advice, care, 
and watchfulness may be depended upon to avert and combat 
complications should they arise, and she should be strongly en- 
couraged to control her instinct for introspection and investiga- 
tion of the details of the entire physiological process of child- 
bearing. Instead, let her report often to her doctor, and send 
unfailingly for his examination every three weeks during preg- 
nancy a sterile, eight-ounce, twenty-four-hour urine specimen 
properly marked. Carrying out the best physical and mental 
hygiene during the whole period of pregnancy possible to her 
condition and circumstances, will most certainly bear good fruit 
for herself and child. 

As previously stated, obstetrical nursing demands a woman 
of superior intelligence, judgment, and special training. A lack 
of proper background of character and personality is almost as 
great a bar to success as is a lack of proper technic. 

The Nurse. — In the engaging of the nurse, the actual date 
of confinement cannot, of course, be given. Nurses should be 
selected only because of their special fitness, and on no other 
ground should they be considered. If patients can possibly be 
brought to appreciate the value of expert nursing at this time 
118 



THE NURSE. 119 

and allow the doctor to employ the nurse, the responsibility for 
her work is thus squarely placed upon his shoulders and there 
is no division of responsibility. When other factors enter into 
the selection complications may inevitably be expected. 

Obstetrical nurses properly qualified usually receive a higher 
rate of pay than do those engaged in other forms of nursing. 

The majority of Nurses' Directories have stringent rules 
concerning general nursing when done by the obstetrical nurse. 
If she specializes she will, of course, take no contagious cases. 
If she does general nursing, she will refuse all contagious work 
for a period of at least one month before her engagement. Much 
argument about the necessity for this procedure exists at present, 
owing to the latest teaching concerning communicable diseases. 

But the carelessness of a few nurses and the susceptibility 
of an obstetrical case for some infectious diseases make it im- 
perative that a nurse use every safeguard that will render the 
danger less. All her personal effects that may have been ex- 
posed, without exception, must be thoroughly fumigated in ac- 
cordance with Board of Health rules. Then all articles that can 
be washed and boiled must be carefully handled. She, herself, 
must by a thorough bath and 95 per cent, alcohol rub, a shampoo, 
completed with a generous application of 95 per cent, alcohol 
and a persistent use of a nose and mouth antiseptic spray, spare 
no effort to make herself a safe obstetrical nurse. 

Pus in any form, such as an otitis, otopyosis, boils, pustules, 
T. B., as well as a very recent attack of a contagious disease, most 
certainly disqualify a nurse. The lesser ills of colds, sore throat, 
tonsilitis, or bronchitis must be left to a physician to decide. 
Rather than make a change, it is quite customary for the doctor 
to permit the nurse to go on duty, but she owes it to herself that 
every possible care be taken to avoid infecting her patients. 
The close nursing and the time covered make very possible an 
unfortunate outcome, unless she fully realizes her duty. This 
can be met best by observing those rules of personal and gen- 
eral hygiene which tend to properly preserve her own health. 

Occasionally nurses lose time waiting for cases, and this 
forms one of its most objectionable features in the eyes of the 



120 A NURSE'S HANDBOOK OF OBSTETRICS. 

average nurse. Nurses should not be called at the last moment. 
It is an objectionable custom, as it defeats, oftentimes, the very 
strongest argument for employing an efficient nurse, namely, 
through lack of time surgical cleanliness cannot always be se- 
cured. It is essential that some definite arrangement be made 
as to the nurse's engagement. The doctor will usually arrange 
this matter and very properly suggest that payment be made 
at the usual rate from a certain date, or he may arrange for 
half pay for the waiting period, the nurse either being on call 
or at the home of the patient. She even may, with the doctor's 
permission, accept calls to clean and brief cases, always with the 
full understanding that she is on call. In any event it is not 
justice to expect her to lose days, even weeks, without full re- 
muneration, and usually her doctor will assume direction of 
affairs and protect her best interests. She must be very careful 
not to let her cases overlap. 

Having completed her engagement of her doctor and nurse, 
the patient will next direct her interest to her own preparations 
for delivery. 

The number of patients preferring to be confined in a hospital 
is rapidly increasing, as a recognition of the many advantages 
enjoyed is becoming more general. To the average woman who 
expects to possess comfort and enjoy a feeling of safety, it 
appeals very strongly. It is cheaper, much safer, and offers every 
possible convenience. It provides against every emergency, and 
obviates all interruptions to the domestic routine, other than a 
temporary absence from the home. Its economy is a strong 
factor in its favor. A special nurse is more often required for 
maternity cases than not, if the fastidious, dainty tastes of the 
patient are to be satisfied. This, of course, with her board is a 
special expense to the patient, but places a nurse always at her 
disposal. 

If such a delivery is not available because of lack of hospital 
facilities, or the preference is for a home accouchement, the 
mother will proceed with her own preparations. 

Beginning at a sufficiently early date in pregnancy to enable 
her to have all her preparations made at least one month before 



THE MOTHER'S OUTFIT. I2 i 

labor is expected to occur, the prospective mother should make 
ready the articles which will be required at the time of her con- 
finement. 

This outfit may be divided into two parts: one consisting of 
the articles needed for the mother's use, and the other of the 
supplies which will be required by the infant. 

In many cases the physician will give the patient a list of 
the supplies he wishes her to get, but where the matter is left 
in the hands of the nurse the following outfit will usually prove 
satisfactory : 

Six abdominal binders, one and three-quarters yards long 
by three-quarters yard wide ; made of the cheapest grade of un- 
bleached muslin. This muslin comes in a width of three-quarters 
yard, and ten and one-half yards are required to make the neces- 
sary number of binders. They should be torn in the proper 
length and then washed and ironed, to make them soft and com- 
fortable. The cheapest grade of muslin is recommended because 
the more expensive, and consequently heavier, quality does not 
take the pins as well and is stiff and uncomfortable when in use. 

Two obstetrical pads for the bed, each twenty-four inches 
square and made of cheese-cloth stuffed with cotton batting (not 
absorbent cotton) until it is three or four inches thick. They 
should be " tacked " or tufted to keep the cotton from slipping, 
and are for use under the patient's buttocks during the first 
few hours after labor when the flow is greatest. 

One dozen clean towels, preferably old soft ones without 
fringe. These are to be pinned up in another towel and laid away 
with the other things. They are for use only about the patient, 
and are not for the hands of the physician or nurse. 

New diapers may be used in place of the towels if desired, 
but old ones may never be employed for this purpose. 

Fifty yards of gauze or cheese-cloth. 

Safety-pins, two papers of large and one of small size, in 
addition to those required for preparing the bed. 

One new nail-brush for the nurse. The physician should 
bring his own. The best for this purpose are those with plain 
wooden backs, costing five or ten cents each. 



122 A NURSE'S HANDBOOK OF OBSTETRICS. 

Four pounds of absorbent cotton. 

Tincture of green soap, six ounces. 

Four breast binders, pattern illustrated. 

Six T-binders. 

Two pieces of rubber sheeting, each one and one-half 
yards square. Of this sheeting one piece may as well be of the 
so-called " enamel cloth " (white) which is often used for cover- 
ing kitchen table and shelves, and is much less expensive. This 
piece may be used for covering the bed upon which the patient is 
delivered, and, afterward, cut into smaller pieces for the baby's 
bed or bassinette. The other piece, of the regular quality to be 
had of the druggist, is for use on the patient's bed during the 
puerperium and, later, by the baby, who will require it for the 
following three or four years. 

TWO PAIRS LONG WHITE COTTON STOCKINGS. 

Two suits white pajamas. To be worn during labor. The 
trousers to be ripped into two stockings. The seam to be hemmed, 
the band cut through the back and two wide capes applied. This 
leaves a wide space before and behind, allowing complete freedom 
to the doctor and at the same time affording the least exposure 
to the patient. The nurse may tie a bandage above the knee, 
keeping any fulness out of the way. The result is an ideal ob- 
stetrical suit much like the Sloane Maternity stocking so widely 
used. Sterile towels will, of course, protect the area of opera- 
tion by being placed over the pajamas. The sterile white cotton 
stockings and the jacket complete an effective obstetrical outfit. 
The T-binder preserves the perineal pad in position. 

One fresh clean dressing gown. 

Six soft old night dresses. 

Four pounds cotton batting. 

Two ounces lysol. 

One hundred bichloride or biniodide of mercury tablets. 

Two OUNCES tincture of iodine. 

Eight ounces saturated solution of boric acid. 

two ounces albolene. 

One pint 95 per cent, alcohol. 

One bed-pan. 

One covered irrigator with complete attachments. 



THE MOTHER'S OUTFIT. 123 

Two wash-basins, preferably of agate- or enamel-ware ; 
after boiling, these will be needed for solutions at the time of 
the labor; afterwards for bathing the patient's genitals during 
the puerperium ; and still later for use about the infant. 

One slop-jar or pail with lid, made perfectly clean and 
used during labor for receiving soiled sponges, towels, as well as 
any solutions or discharges that can be directed into it. 

One tub in which to immerse the infant. 

One bowl, for cracked ice. 

Six pitchers or vessels, to hold hot and cold water. 

A good supply of clean towels (in addition to the dozen 
already mentioned), and plenty of sheets, pillow-cases, and 
night-gowns for the patient's use. Nothing is more annoying to 
the physician than to call for a clean sheet or night-gown at 
such a time, and find that it is not to be had. Clean towels, al- 
most without number, are needed in the lying-in room. 

The chapter on The Normal Infant contains a list of the 
necessary outfit for the infant. 

TO BE STERILIZED 

Gauze packing 10-yard length }4-yard wide, sterile, and in 
sterile jar; for uterine packing. 

Folr dozen perineal pads of cotton covered with gauze to 
fit the patient and meet the binder. In packages of three each. 

One pound of absorbent cotton sponge balls, 3 inches in 
diameter ; in a preserve jar. 

Fifty gauze sponges, 4 inches square, for operative use ; in 
a preserve jar. 

One test tube containing umbilical tape, with cotton 
plug and rubber cap. 

A supply of assorted sizes old linen squares, in a jar. 

TWO I YARD SQUARES OF MATTRESS PAD MATERIAL. 
TWO PAIRS OF LONG WHITE COTTON STOCKINGS. 

Two suits of pajamas, for the patient. 
One suit of pajamas, for husband. 
One dozen soft old towels, 
two dozen towels. 



124 A NURSE'S HANDBOOK OF OBSTETRICS. 

Twelve sheets. 
Six pillow-cases. 

two night-dresses. 

slx abdominal binders. 

Six T-binders. 

Six breast binders. 

two papers of safety-pins. 

Four brushes, two each in a preserve jar. 

One-half pint milk bottle, to hold the solution for nurse's 
forceps. 

The irrigator, tubing, bed-pan, wash-basin, pitcher, should 
all be scrubbed, boiled, and wrapped in a sheet and placed away. 

The dressings can often be made by the patient if she is shown, 
otherwise they are prepared and sterilized by the nurse. Econ- 
omy in the use of all supplies is imperatively demanded of the 
nurse. Much complaint is heard of the great extravagance of 
many otherwise valuable women. 

It is usually a simple matter to have the necessary sterilization 
of supplies done, as a great many hospitals or nurses' directories 
arrange for this. Usually a small charge is made. Many dif- 
ferent sets of obstetrical outfits are on the market. These are 
not always satisfactory, and are expensive. Some hospitals 
rent very complete obstetrical baskets, the articles outside of 
the dressings to be returned. This is a very desirable and con- 
venient arrangement, as the sterilization may be investigated 
and technic verified. A nurse may possess a small portable 
sterilizer; several good ones are on the market. Sterilization 
may be properly done in the patient's home with one of these. 
Occasionally the nurse may go to the patient's home and in the 
absence of other facilities proceed, as she has been taught, to 
boil, steam and dry the small packages, all indelibly marked upon 
their cotton wrappings. All the surgical dressings and cord 
dressings, however, must be freshly purchased. Such steriliza- 
tion is at best not perfect and should not be relied upon for 
such dressings, 



XIII 

Preparations for Labor (continued) 

These begin with the making or purchase of the supplies 
described in the preceding chapter, and end with the selection, 
furnishing, and preparation of the lying-in room. 

The room in which the confinement is to take place is to be 
chosen with great care, for it must serve first in the capacity of 
a hospital operating-room and afterwards meet the requirements 
of a cheerful and comfortable bedchamber, in which every want 
of a convalescent patient can be met promptly and satisfactorily. 
For these reasons there are two prime factors in the choice of 
the room which can never be safely overlooked. First, it must 
be scrupulously and surgically clean ; and second, it must be 
bright, spacious, properly lighted, well heated, and thoroughly 
ventilated. 

The nurse is, of course, limited in her selection of a room for 
this purpose to the possibilities of the house in which the patient 
resides, but no room is too good for the business in hand, and 
she is at perfect liberty to make use of even the parlor or dining- 
room if it seems best suited to her needs. Naturally, the nurse 
will avoid putting the family to any unnecessary inconvenience, 
but her first thought must always be in the interest of her patient. 

The ideal lying-in room is one that is large, sunny, provided 
with an open fire-place, and with a well-equipped bath-room 
adjoining, or at least on the same floor. It should be situated in 
a part of the house that is quiet and as far as possible from the 
odors of the kitchen and other unpleasant features. 

The nurse must make sure that the room has not been occu- 
pied within at least six months by a patient suffering from any 
contagious, infectious, or suppurative disease, and if such is 
found to have been the case the room is to be condemned and 
another, though possibly a less convenient one, chosen in its 
place. If, for any reason, it is impossible to make use of another 

125 



126 A NURSE'S HANDBOOK OF OBSTETRICS. 

room, the infected one is to be thoroughly disinfected in ac- 
cordance with the rules of the Board of Health with which every 
nurse should be familiar, and then entirely dismantled, and re- 
painted and repapered throughout. 

In any event, the lying-in room is to be thoroughly cleaned 
and all the wood-work wiped off with damp cloths at least two 
weeks before the expected date of the labor; and all curtains, 
draperies, portieres, and other articles that can collect dust are 
to be banished. In the same way, all unnecessary furniture is to 
be removed and only enough left to make the room comfortable 
and cheerful. Carpets should be taken up if possible. When 
this is not possible, they should be well protected by a large 
rubber sheet, or by many thicknesses of newspaper covered 
with sheets and tacked down. Rugs can be easily removed 
without causing dust and confusion. The patient will need 
a comfortable chair and a firm single metal bed. These are now 
very common and are generally found in every home. The doc- 
tor will need a plain table, from a hall or kitchen. The nurse 
will need a table for supplies. Another table or chairs will be 
needed, and the bureau and washstand will occupy the balance 
of space properly required. 

All this can be quietly and expeditiously arranged, and the 
nurse may secure the patient's approbation of this preparation 
if the matter is intelligently and tactfully presented. In the 
event of an emergency arising and every second of time being 
valuable, the wisdom of the arrangement is obvious. The pa- 
tient may be much interested and assist the nurse in planning the 
arrangement of furniture and supplies. 

If this is carefully arranged and the patient made to under- 
stand what is required, the household will be much less upset 
than when a sudden demand for instantly required articles is 
made upon it. 

In hospitals the details for maternity work are complete. 
In homes of small means, the economy of the preparations is of 
vital importance to the patient. The nurse can be most helpful 
here, by her ability to confine requirements to the limit of effi- 



THE INFANT'S BED. 127 

ciency and safety with the minimum domestic upheaval and 
expense. 

In short, the room is to be as clean and free from dust- 
collecting and germ-breeding articles as it is possible to make 
it, and the nurse who has been thoroughly drilled in aseptic and 
antiseptic methods will understand what is required without 
further argument. 

The infant should never, under any circumstances, be allowed 
to sleep with its mother, and its bed may be either the crib that 
it is to occupy during its childhood or a bassinette designed for 
use only in its infancy. In emergency cases, where neither of 
these is at hand, a temporary bed may be made for the baby out 
of a box, a large trunk-tray, or a bureau drawer ; or it may sleep 
on a couch or in a large arm-chair. Two ordinary cane-seated 
chairs, placed against the wall and with a hair pillow or cushion 
for a mattress, make an excellent temporary bed. 

Bassinettes may be purchased in any style and at any price 
to suit the taste and the pocket-book of the purchaser, or a very 
pretty one may be made at home with a clothes-basket as a 
basis and barrel hoops wound with ribbon to support the 
draperies. As a rule, the chief objection to the bassinette is its 
great depth, and as an infant needs plenty of fresh air it is not; 
benefited by spending the greater part of its time at the bottom 
of a deep basket, surrounded and entirely shut in by curtains and 
hangings. In selecting or designing a bassinette, the top of the 
infant's bed should never be more than four inches below the 
top of the basket or framework, and if the nurse finds one 
ready for use in which this depth is exceeded she should raise 
the level of the bed by placing under it a folded blanket or a 
pillow. The bed should be of hair and never of feathers, or the 
infant will sink down into it and be hot and uncomfortable from 
the first. These bassinettes are dainty in appearance, but far 
from desirable. A metal bassinette or crib is better from every 
point of view. A specially good type is one which can be swung 
within the mother's reach when necessary. 

The mother's bed should be the best that the house affords, 
for the period of convalescence after labor is the more trying to 



uS A NURSE'S HANDBOOK OF OBSTETRICS. 

the patient the more nearly it is normal ; and unless her bed is 
a comfortable one it is often a very difficult matter to persuade 
her to keep in it for the required number of days. The springs 
should be good and the mattress firm and solid. 

Unless it is absolutely necessary this bed should never be the 
one in which the woman is confined, and for this purpose a 
single metal bed with a very low foot bar should be provided. 
The many advantages of a single metal bed have made the latter 
extremely popular, and few homes are unwilling to purchase 
one, if their desirability for delivery is properly represented. 
Their possession in a home is a real economy, as some provision 
must always be made for the nurse. Couches are often insanitary 
and generally uncomfortable ; cots are always unsightly as well 
as uncomfortable, particularly for a heavy patient. If the metal 
bed purchased be very plain and as high as 28 inches, it will 
not only serve for the patient's use but later on the nurse may 
use it. Afterwards it may prove of special service for any 
member of the family in case of sickness. 

If the usual double bed with box mattress is encountered, 
all draperies must be detached, the bed scrubbed with soap and 
water and washed off with 2 per cent, solution of lysol, and the 
head- and foot-boards covered with sterile sheets immovably 
fastened. 

If the labor takes place in an ordinary double bed, it is ex- 
tremely difficult for either the physician or the nurse to " get at " 
the patient conveniently, on account of its width and the pres- 
ence of the head-board and foot-board; while if any operative 
work becomes necessary, or an emergency arises, the awkward- 
ness of the situation is more marked than ever. On the other 
hand, if a single bed is used the patient is accessible from all 
sides, and the case can be managed as easily and conveniently as 
on a hospital operating-table. 

The preparation of the bed or beds depends upon whether 
one or two are to be used. If but one bed is provided, it must be 
so arranged that, after the labor, it can be rearranged quickly 
and easily and put into a clean and comfortable condition with- 
out disturbing the patient to any great extent. The best way 



PREPARATION OF BED FOR LABOR. 



129 



to accomplish this is to first prepare the bed as it is to be during 
the puerperium and, then to add the necessary preparations for 
the labor. 

The mattress is to be supported from below by means of 
boards slipped in between it and the springs, so that it will be 
perfectly firm and level during the labor and not sag down in 
the slightest degree. Boards may be made expressly for this 





Fig. 55. — Showing manner of elevating bed, showing draw-sheet and rubber sheet folded 
back, leaving fresh bed beneath. 

purpose, or table-leaves or slats from another bed may be used. 
They are to lie crosswise of the bed, at a point directly under the 
patient's buttocks, and should be removed at the conclusion of 
labor. Their use facilitates all the work about the patient, and 
by keeping the mattress perfectly flat prevents the blood and 
other discharges from collecting in a pool under the patient's 
back. 

The mattress is now to be covered with a piece of rubber 
9 



130 A NURSE'S HANDBOOK OF OBSTETRICS. 

sheeting pinned securely at the sides and corners so that it will 
not slip ; over this is to be placed a white sheet pinned in the same 
way, and over this a draw-sheet, also carefully pinned. 

This is the correct arrangement of the sheets for the puer- 
perium, and they must be protected for the labor by covering 
them with another rubber sheet or " enamel cloth " and white 
sheet, both of which are to be pinned securely all around. 

After the labor is over the uppermost white sheet and rubber 
sheet are removed, and the patient lies on the white sheet and 
draw-sheet underneath. 

If two beds are used, the mattress of the cot on which the 
labor is to occur is supported with boards, as in the first in- 
stance, and protected with a rubber sheet covered with a white 
sheet, both of which are securely pinned on all sides. 

The other bed is then made ready (in the manner already 
described) with rubber sheet, white sheet, and draw-sheet. On 
the draw-sheet should be placed one of the obstetrical pads from 
the maternity outfit, in such a position that it will come directly 
under the patient's buttocks when she is laid in bed. 

Unless the various coverings are carefully and securely 
pinned they will become greatly disordered by the tossing and 
turning of the patient, and in protracted cases they may even be 
torn entirely from the mattress and cast on the floor. 

The nurse should see that the provisions for lighting the 
room at night are ample, and that it is warm and comfortable in 
every way. 

The hair about the vulva should be closely clipped and the 
parts shaved. This is part of the ordinary routine in hospitals, 
and a skilful nurse handling a safety razor occupies a very 
few minutes at this. These final preparations are usually most 
distasteful to the patient, but tact and intelligence will usually 
overcome all objections. If this procedure is strenuously op- 
posed, the nurse will, of course, withhold argument, and exer- 
cise great care in the cleansing of the external genitals. 

Occasionally the doctor prefers not to have the patient shaved 
or even clipped closely. It is best to be informed of his wishes. 

The physician should be summoned as soon as labor-pains be- 



PREPARATION OF PATIENT. 131 

gin, unless he has given definite instructions to the contrary. Some 
physicians prefer not to be called to a case until, in the opinion 
of the nurse, the first stage is nearly at an end, but even under 
these circumstances it is better that he should know that the 
woman is in labor, so that he will be prepared to respond 
promptly to the second call. 

After the messenger has been despatched for the doctor 
the patient should be given an enema of soapsuds, one pint, and 
spirits of turpentine, one teaspoonful. This will effectually 
empty the lower bowel, and render the labor not only easier but 
infinitely more cleanly, and must never be neglected. This may 
have to be repeated and the nurse must watch closely the move- 
ments of bowels and urine, reporting promptly failure to secure 
movement or inability to urinate normally. 

It is distinctly to be remembered that enemata may be given 
through a rubber bag. But the bag, even if new, is improper 
for use in administering an infusion, hypodermoclysis, or sterile 
douche. It cannot be cleansed properly, and boiling it for twenty 
minutes soon destroys it. These bags are very apt to be used 
for many objectionable purposes, even boiling not rendering 
them safe for sterile obstetrical practice. The use of such bags 
is a grave and very common fault, and it vitiates the other- 
wise dependable technic of many doctors and nurses. The 
same tubing should never be used for sterile treatment and 
enema. There is rarely time to thoroughly boil it, even granted 
that there are facilities ; and the risk should never be taken. 
Enamel covered cans are the safest for a nurse to use. They 
may be easily and thoroughly cleaned and boiled and leave no 
doubt as to their aseptic condition. 

The patient should now receive a thorough general bath with 
plenty of soap and warm water. After the bath her hair is to be 
well brushed and braided in two braids, and she is to be dressed 
in sterile pajamas, sterile stockings, and slippers, over which she 
will wear a wrapper or bath-robe than can be slipped off and on 
easily, preferably new, but certainly freshly laundered. While 
taking the bath, the'patient should be caused to stand in the tub, 
which is to be partly filled with warm water so that her feet will 



[ 3 2 A NURSE'S HANDBOOK OF OBSTETRICS. 

not be chilled, and then given a thorough sponge-bath, after 
which she may be showered, either with a spray or with water 
poured over her from a pitcher. 

This is to be more than ordinarily cleansing. It should in- 
clude a brisk scrub, using surgeons' soap and crash cloth over 
the whole body, particularly the area of possible operative ex- 
posure, and paying special attention to the vulva. This is to be 
followed by a flushing with warm water, to remove the soap ; 
then a pitcher of lysol solution, i per cent, is flushed over this 
area, or 95 per cent, alcohol applied with a sterile sponge. The 
vulva then receives a final cleansing. Here, as always, the spong- 
ing is toward the rectum. The patient is given a friction rub. 
The sterile pad is now put in place and held by a T-binder and 
the patient is instructed not to touch it. In rural districts or in 
tenements neither bath-tubs nor showers may be available. The 
patient must then stand upright in a tub of warm water and the 
same method be followed. 

While the patient is occupied with her bath the lying-in 
chamber is to be prepared for the labor, and the bed or beds prop- 
erly made up. If the patient has been sleeping in the bed in which 
she is to be confined, it is to be completely dismantled and 
supplied with clean bedding throughout. A chair is to be placed 
at the right side of the bed, facing the head, ^or the physician, 
and a table (preferably a low cutting-table) covered with sterile 
white towels should stand within easy reach of his right hand. 
The slop-jar or pail is to be placed so that the apron of the physi- 
cian's Kelly pad will drain into it. 

Many physicians have discarded the Kelly pad in actual ob- 
stetrical work, on the ground that its use is not practical and on 
account of the difficulty in properly cleaning and disinfecting it. 
Where one pad is carried about and used for all purposes its use 
is vicious. 

If the doctor prefers to use one, the nurse must see that it is 
thoroughly scrubbed with a brush, and soap, then rinsed off with 
a solution of bichloride of mercury 1 : 1000, wrapped in a towel, 
and boiled for five minutes. 

From this moment the use of the water-closet must be 
absolutely forbidoex. Evacuations of urine and faeces are to 



PREPARATION OF ROOM FOR DELIVERY. 



133 



be received in a boiled vessel, which is to be removed at once 
from the room, emptied, cleaned thoroughly, boiled for five 
minutes, and returned with as little delay as possible. The vulva 
pad, which must, of course, be removed when the rectum or 
bladder is emptied, is in every instance to be replaced by a fresh, 
clean one after the parts have been sponged according to the 
technic given. 

The nurse should see that the lying-in room is warm, well 
lighted, and arranged according to directions ; that all supplies are 
at hand and in order ; that there is an ample supply of cold boiled 
water ; that there is a good fire in the kitchen stove, unless a gas 
stove is available, and that plenty of water is actually boiling ; that 
the instructions relative to the patient have been conscientiously 
carried out ; and, lastly, that all children and other unnecessary 
individuals are out of the way. Unless the doctor requires his 
help, it is not usual for the husband to remain in the room after 
the first stage, the doctor usually excusing him. 

From the moment the nurse comes on duty she will keep a 
careful record of her patient. This she will continue, however 
long the case may be. 

The room will be furnished as follows at time of delivery : 

A single metal bed, with a firm spring, and made up according 
to technic for delivery. 

Small zvooden table with chair, at head of the bed, for anaes- 
thetist's supplies. Here also will be the hypodermic syringe and 
needle, tested and ready for instant use. The two 2-quart jars 
of sterile saline solution, kept warmed by being placed in hot 
water, ergotole, ergot, tincture of iodine, sterile solution of cam- 
phor in olive oil, alcohol, pituitrin, or other drugs, asked for by 
the physician. 

The tray for the C rede's treatment, and a kidney basin for 
emesis. All of these should be in instant reach and with no 
chance for confusion. 

Doctor s Table. Scrubbed thoroughly, and covered with a 
sterile towel. Basin containing a 2 per cent, solution of lysol, 
and cotton sponges, for bathing the vulva. Basin of hand solu- 
tion of lysol, 1 per cent. Dish or tray with tape, forceps, two 



134 A NURSE'S HANDBOOK OF OBSTETRICS. 

artery clamps, scissors and rubber catheter, pair of rubber gloves 
pitcher of hot sterile water, and six sterile towels. This must be 
within reach of his right hand. 

Bureau for sterile, packages and solution of lysol, 2 per cent., 
for cleansing vulva. Jar of lysol, 2 per cent, for nurse's forceps, 
gowns for use of physician and nurse, suits for patient and 
husband will all be plainly marked and so easily distinguished. 
Package of gloves for doctor and nurse will be here, unless they 
were sterilized by boiling for 10 minutes and have been put 
in a basin of sterile solution on the doctor's table. 

Washstand for scrub-up technic. Follow the technic of the 
doctor in attendance. Generally a doctor will prefer to do the 
preliminary cleansing in the bath-room with running hot water. 
The boiled tampico fibre brushes will be ready in a sterile 2 per 
cent, solution of lysol, the covered jars preventing contamination. 
Tincture of green soap is always used. After scrubbing with 
care and cleansing around and under finger-nails with file, the 
hands may be soaked in solution of bichloride of mercury, 
1 : 2000, for five minutes, or 95 per cent, alcohol may be sponged 
over them for five minutes, or lysol, 2 per cent., or carbolic, 
1 : 1000, or soda and lime, or permanganate and oxalic acid. 

Whatever his choice, the solution must be prepared, and an 
abundance of boiled water must be at command. 

Small foot or infant bath-tub on chair for resuscitation of 
infant by immersion with an attached bath thermometer. 

Basket for infant with hot-water bottle and blanket. 

Sterile bed-pan. 

Sterile irrigation outfit for infusions or douches. 

Abundance of sterile pitchers and vessels. 

All exposed surfaces on bed, tables, bureau, and washstand 
must have sterile covers. 

A covered slop-jar or pail. 

A hook or bandage on irrigator handle to facilitate attach- 
ment. 

A chair for the doctor. 

The mother's preparation for the infant is outlined in the 
chapter on " The Ideal Nursery " and will be found to be a 
conservative guide. 



XIV 

The Conduct of Labor 

Normal labor may be defined as labor which is terminated 
without artificial assistance and which leaves the mother in good 
condition, beyond a slight feeling of exhaustion and sense of 
fatigue. It might perhaps better be termed " unassisted labor," 
for surely an easy and rapid breech delivery, which occasionally 
occurs and which is in one sense to be regarded as a distinct 
abnormality, is to be preferred to a protracted and difficult vertex 
case which subjects the mother to great suffering and more or 
less shock. 

For practical purposes, then, so far as the nurse is concerned, 
we may regard as normal any labor which is accomplished within 
a reasonable length of time without manual or instrumental 
interference. 

In the cases most likely to come under the care of the trained 
nurse in private practice she will often be summoned several 
days or even weeks before the onset of labor, and so will be in 
a position to observe its phenomena from the very first. 

It is assumed that all the preparations named have been made, 
and that everything is in readiness for the expected event. 

For a varying period before the establishment of true labor- 
pains the patient will often suffer from so-called " false pains," 
and the nurse must be able to distinguish between them and 
effective uterine contractions. 

False pains may begin as early as three or four weeks 
before the termination of pregnancy, and they are merely exag- 
gerations of the intermittent uterine contractions which occur 
throughout the entire period of gestation, combined with the 
effects of pressure on the abdominal tissues as the uterus and its 
contents settle down in the pelvis. They occur at decidedly 
irregular intervals, are confined chiefly to the lower part of the 

135 



136 A NURSE'S HANDBOOK OF OBSTETRICS. 

front and sides of the abdomen and groin, never extending 
around to the back, and are short and ineffective. They are 
more annoying than painful, and are never accompanied by any 
actual " bearing-down" sensation. The primigravida often re- 
gards them as true labor-pains, and marvels at the ease with 
which she bears them, but the woman who has borne children 
or the experienced obstetric nurse is seldom if ever misled by 
them. 

True labor-pains occur with a regularity that is almost 
perfect, and if they are timed by the clock it will be found in the 
majority of cases that, at the beginning, they will occur at inter- 
vals of about half an hour and that the periods between them 
will be exact almost to a minute. In timing the pains in this 
way the nurse should not let the patient know what she is doing, 
as the knowledge may have a suggestive influence on their fre- 
quency. 

The gradation between false and true pains is an almost im- 
perceptible one, the first indication of the appearance of true 
pains being usually the establishment of this regularity in their 
recurrence. Soon, however, the true pains begin to take on their 
characteristic qualities. They become longer and somewhat 
more painful. Beginning in the back they extend around to 
the front, the sensations in the front of the abdomen remaining 
after those in the back have ceased, and they are accompanied 
by a distinct " bearing-down" feeling. True pains cannot be 
said to be especially painful in the early part of the first stage, 
but the patient usually realizes fully that her labor has begun, and 
her face often wears a somewhat anxious expression, with a 
slight flushing and drawing of the features at the acme of the 
pain. 

As soon as the nurse has decided, from the character of the 
pains, that labor has actually commenced, she should notify the 
physician in charge of the case. It does not necessarily follow 
that he will respond personally to this notification, but it is 
proper that he should know that his patient is in labor, so that 
he can arrange his time and engagements and be ready to answer 
promptly the second and peremptory call. If the patient is to 



TRUE LABOR-PAINS. 137 

go to a hospital for confinement, the order to start is usually 
given by the attending physician ; and the nurse must have matters 
so ordered that she may start with her patient at a moment's 
notice. If there is no nurse the patient must be ready to go 
when the true pains begin. 

As soon as the physician has been notified the nurse should 
begin to arrange the room for the labor, being guided as to haste 
by the frequency of the pains. 

The room is to be warm (70 to 72 ° F.), well lighted and 
well ventilated ; hot and cold sterile water and provision for 
boiling the physician's instruments are to be provided ; and the 
needed supplies described are to be arranged in a convenient 
manner and place. The patient is to receive an enema of soap- 
suds, one pint, and spirits of turpentine, one teaspoonful, and 
is then given a warm bath, as described, or by sponging, as the 
circumstances will permit. The external genitals are to be 
cleansed with special' care, and the pudendal hair, if long and 
abundant, must be clipped short with scissors or shaved with a 
safety razor. 

The patient's hair is to be braided neatly in two braids ; she 
is dressed in a sterile suit of pajamas arranged as directed for 
obstetric use, or a pair of woven obstetrical stockings. If no 
such preparations have been made a clean night-gown with 
slippers, and bath-robe may suffice ; and a vulva pad is applied 
and pinned to a band, to protect the parts and absorb any dis- 
charge that may escape from the vagina. 

From the beginning of the true pains the patient is not to be 
allowed to use the water-closet under any circumstances what- 
ever, and if the enema of soapsuds and turpentine has been 
effective, she will have no occasion to do so except to empty the 
bladder. This need, however, will usually be frequent, and the 
urine is to be voided in a clean vessel, which is to be removed at 
once from the room, cleaned thoroughly, and returned with as 
little delay as possible. It will, of course, be necessary to remove 
the vulva pad when the urine is voided, and after the act has 
been accomplished the external genitals are to be bathed care- 
fully and a fresh vulva pad applied. A pad that has once been 



138 A NURSE'S HANDBOOK OF ( >BSTETRICS. 

removed must never be replaced, no matter how clean it may 
appear to be, and there ean be no exception to this rule because 
of the danger of carrying infection to the vulva. 

The woman is to be encouraged to keep on her feet the 
greater part of the time, to favor descent of the head into the 
pelvis, and the nurse should endeavor to make this trying ordeal 
as light as possible by cheering words and a hopeful manner. 
The patient is to be dissuaded from attempting to help herself 
by voluntary straining of the abdominal muscles, for such efforts 
do no good at this time and only exhaust her and' wear out her 
strength ; and it is even a good plan to keep up her energy 
during the first stage by providing some light refreshment, such 
as tea and toast or soda-biscuits, of which she can partake when- 
ever she feels so disposed. 

If the membranes rupture in the first stage the danger of 
prolapse of the cord must be kept in mind, and the physician 
should be notified immediately, but this should be done without 
the patient's knowledge, for, especially if it is her first labor, the 
accident is apt to cause her great alarm. She should be informed 
at once of the nature of the watery discharge, and assured that 
it is a perfectly natural phenomenon and of no consequence 
whatever. If her night-gown or other garments have become 
soaked wifh amniotic fluid, they must be replaced at once with 
dry clothing. 

When the pains occur as often as every five minutes the phy- 
sician is to be summoned peremptorily, and even sooner than 
this if he lives at a considerable distance from the patient or in 
case there is any difficulty in getting word to him. Many phy- 
sicians give the nurse positive orders as to when they wish to 
be called, but in the absence of any such explicit directions 
she may regard the above rule as a safe guide in the majority 
of cases. 

This degree of frequency in the occurrence of the pains is a 
fair indication of the beginning of the second stage of labor, and 
when the pains take on the characteristic features of those of the 
second stage the diagnosis of the condition is not at all difficult. 
The pains of the second stage are longer, much more severe, 



PRELIMINARY EXAMINATION. 



139 



and the patient's face is suffused with blood until, at the height 
of the pain, it is almost cyanotic, while the neck swells and 
the large blood-vessels stand out like knotted ropes and pulsate 
violently. 

As soon as it is apparent that the patient is in or near the 
second stage of labor she is to be put to bed, for at this time the 
os uteri is, of course, fully dilated, and if she is allowed to 
remain on her feet precipitate labor may occur. As a rule, the 
patient is quite willing to go to bed when this period of labor is 
reached, and in many cases she is unable to keep up any longer 
even if she were allowed to do so. 

The nurse should have ready, on the arrival of the physician, 
hot water, soap, a nail-brush for the disinfection of his hands, 
antiseptic solution (usually bichloride solution, 1 to 2000) sterile 
rubber gloves and solution of lysol, 2 per cent, or lubrichondrin. 
As many physicians, unfortunately, neglect to provide them- 
selves with an apron or gown, the nurse should also have in 
readiness a small clean sheet, which can be pinned around his 
neck and again about the waist, making a fairly good substitute 
for an operating-gown. 

After the arrival of the physician he will, of course, take 
charge of the further management of the case, and, if the patient 
is still on her feet, decide when she is to be put to bed. 

If the case is at all advanced the physician will wish to make 
a vaginal examination at once, in order to determine the amount 
of dilatation of the cervix and inform himself as to the progress 
that the woman has made, and while he is disinfecting his hands 
the nurse will prepare the patient for examination. 

The woman is to lie on her back, on the right side of the bed 
near the edge, covered with two clean sheets, each folded in half 
and arranged as follows : one sheet is to lie across the bed, 
covering her lower limbs and extending from the foot-board to a 
point midway between the patient's knees and hips ; the other, 
covering the rest of her body, also lies crosswise of the bed and 
overlaps the first by a few inches (Fig. 56). Before the sheets 
are finally adjusted the nurse will remove the vulva pad and 
carefully bathe the external genital organs with warm sterile 



I 4 o A NURSE'S HANDBOOK OF OBSTETRICS. 

water and tincture of green soap, and a fresh piece of absorbent 
cotton, using the sponge in dressing forceps and not in her fingers. 
When the physician has completed the disinfection of his hands 
and put on a pair of boiled rubber gloves, the nurse will squeeze 
some lubrichondrin from a collapsible tube on his index and 
middle fingers, taking care that neither the tube nor her own 
hand comes in contact with the examining fingers. The patient 
should now be directed to draw up and widely separate her knees, 
while the nurse raises the upper of the two sheets so that the 
physician can see the vulva, and holds it in such a position that it 
cannot come in contact with his hands, but serves as a screen to 
prevent the woman from appreciating the extent to which she is 
exposed. 

The writer prefers this method to the older one of covering 
the limbs and abdomen with a single sheet arranged in " horse- 
shoe " form which is always getting in the way or becoming 
disarranged, and which, from the nature and method of its ad- 
justment, is far more suggestive to the patient than the one 
described in detail.- 

If the physician's outfit contains a Kelly pad, it is to be placed 
under the patient, with its apron draining into the slop- jar or pail, 
and covered with a clean towel tucked well under the edges of 
the pad, so that it will not easily slip out of place. 

The nurse is to see that fresh solutions for the hands are 
always ready and at a proper temperature (ioo° F.) ; that soiled 
or bloody towels and sponges are removed at once from the 
room, or at least kept out of sight as far as possible ; that scissors 
and tape for tying the umbilical cord and boric acid wipes for the 
infant's eyes and mouth are ready the moment they are needed ; 
and that a warm woolen blanket is provided to wrap the baby 
in as soon as it is born. 

All the instruments required are, of course, to be provided 
by the physician, and he will, on his arrival, hand over to the 
nurse whatever he thinks he may need for the particular case, 
which are to be boiled at once for fifteen minutes so that they 
will be ready the moment they are called for. In perfectly nor- 
mal cases about all that are needed are scissors, catheter, and 



CONDUCT OF SECOND STAGE. 141 

douche-tube, but some physicians add to these a dressing-forceps 
and a tenaculum or volsellum. In emergency cases, when there 
is nothing at hand, an ordinary pair of clean scissors and a piece 
of new white cotton twine may be boiled and used for cutting 
and tying the cord. 

During the second stage, when the pains are most severe, the 
nurse should use every art at her command to encourage the 
patient with reassuring words and helpful assistance. A great 
deal can be done to add to the comfort of the patient by holding 
her hands at the height of the pains and, in the intervals between 
them, by rubbing her back and legs, which are often lame and 
cramped. Many women like to have something to pull on as 
the pains occur, and there is no objection to fastening a twisted 
sheet to the foot of the bed, on which the patient can brace 
herself, as it were, when her suffering is most severe. 

Ether or chloroform is indicated at this stage unless there are 
positive objections to its use, and in normal cases the duty of ad- 
ministering the anaesthetic usually falls to the nurse. The patient's 
face should first be well anointed with vaseline to prevent irrita- 
tion of the skin by the drug, her clothing is to be loosened about 
the waist and neck to remove any possible interference with res- 
piration, and false teeth, chewing gum, or any other foreign sub- 
stance that may be in the mouth is to be taken out, lest it should 
be swallowed as the patient loses consciousness. In these cases 
the chloroform is to be given to the " obstetrical degree " only. 
That is to say, it is to be administered only at the beginning of 
each pain and continued only as long as the pain lasts. This 
will be enough to benumb the nervous system and " take the 
edge off the suffering," but the patient will at no time be entirely 
unconscious, and in the intervals between the pains she will be 
perfectly rational. In operative cases, where complete surgical 
anaesthesia is required, the nurse should not be expected to 
shoulder the responsibility of administering the anaesthetic, espe- 
cially as her services will undoubtedly be needed as direct assist- 
ant to the operator, and another physician should be called in to 
act as anaesthetist. 



142 



A NURSE'S HANDBOOK OF OBSTETRICS. 



The best method of administering chloroform is with the 
Esmarch outfit (Fig. 57), which consists of a mask and a 
dropper bottle. The bottle is filled about half full of chloroform 
and corked, and when the stoppers are removed from both the 
little tubes that pass through the cork the contents will escape 
in a fine stream from the smaller of the two when the bottle is 
tilted to the proper angle. Before beginning the administration 
of the anaesthetic the skin of the face must be anointed with 
vaseline and the eyes shielded with a folded towel as a pro- 





Fig. 57. — Esmarch outfit for the administration of chloroform. Dropper-bottle and mask. 

tection against the irritating action of the drug. The mask is 
placed over the nose and mouth of the patient at the begin- 
ning of a pain and the material with which it is covered is kept 
wet with the anaesthetic as long as the pain lasts (Fig. 58). 
The mask is to be removed from the face at the end of each pain 
and not replaced until the beginning of the next one, and a close 
watch must be kept of the patient's pulse and especially of her 
breathing and the general appearance of her countenance. Irreg- 
ularity of the pulse, failure of respiration, and sudden pallor are 
all danger symptoms, and the physician's attention must be called 
to them at once if they appear. 

In the absence of the Esmarch inhaler the drug may be 
administered on a small handkerchief folded square and held 
over the face about an inch and a half from the nose. Care must 



CHLOROFORM. 



1 43 






be taken not to let the handkerchief approach the face closely, 
for, unlike ether, which is to be inhaled in its full strength, chlo- 
roform must be diluted with a large proportion of air (ninety 
per cent.) to be taken with safety. 

When chloroform is administered at night by either gas- or 
lamp-light, many persons, including physicians and nurses, suffer 
from irritation of the larynx of a most severe type, due, probably, 




Fig. 58. — Administration of chloroform. Patient's eyes protected by folded towel; 
third finger of nurse's right hand taking pulse at the facial artery under the margin of 
the jaw. 



to the disintegration of the drug by the flame and the liberation 
of chlorine gas. This causes paroxysms of coughing which 
often make it necessary for the sufferer to leave the room, and 
in one case at least death has resulted from the violence of the 
attack. The patient usually escapes because she is anaesthetized 
to such a degree that the irritating effect of the chlorine is 
unnoticed by her larynx. 



144 



A NURSE'S HANDBOOK OF OBSTETRICS. 



This untoward action of the drug can usually be prevented 
by keeping a good-sized cloth soaked with ammonia hanging 
from the chandelier or near the lamp. The ammonia will com- 
bine with the chlorine to form the bland and unirritating muriate 
of ammonium. Care must be taken, of course, to avoid over- 
doing the matter and making the remedy as bad as the disease 
by rilling the room to suffocation with the fumes of ammonia, but 
this will not happen if the ammonia cloth is merely kept wet with 
the liquid. It must hang near the light, and if any irritating 
effects of the chloroform are felt more ammonia must be used, 
for a sufficient quantity will almost invariably produce the de- 
sired result. 

Until recently ether was rarely used in obstetrical practice, 
though it has always found favor with certain operators. Chloro- 
form being much easier to administer, had always been considered 
(when administered to the obstetrical degree) as attended with 
little or no danger. This fancied security is disproved by recent 
investigation and it has been found to be far from possessing 
innocent freedom from risk. There seems to be a strong leaning 
toward ether as the less dangerous drug, in cases even suggest- 
ing involvement of the mother's kidneys or liver. 

Chloroform is said to produce in susceptible patients a very 
grave " selective " poisonous effect upon the liver of both infant 
and mother, resulting in alarming symptoms of toxaemia, and 
seemingly it is responsible for a serious jaundice in both pa- 
tients, along with other symptoms. For this reason, the use of 
ether is more general than formerly. Its use near an open fire- 
place or gas flame is dangerous. However, if great care is used 
and the can opened and kept at a considerable distance from the 
flame, there is said to be no danger. 

The method of administration of ether differs materially 
from that of chloroform, and, while ether is in many ways the 
safer of the two drugs, its proper exhibition calls for greater 
skill and experience and will not, ordinarily, be required of the 
nurse unless she has had special training in its use. In emer- 
gencies, however, the nurse may be called upon to anaesthetize a 



ETHER. 145 

patient with ether instead of chloroform, and a brief description 
of its administration may be of value in this place. 

As in chloroform anaesthesia, the patient's clothing must be 
loosened at every point, so that her respiration will be absolutely 
unhampered, and any false teeth or other loose objects must be 
removed from her mouth. The woman lies flat on her back, with 
no pillow under her head, and during the entire period of anaes- 
thesia the neck must be extended and the lower jaw held up by 
pressure against the chin to prevent closure of the epiglottis and 
interference with respiration. Several towels must be within easy 
reach, as vomiting is very apt to occur during the inhalation 
of the drug. 

Many forms of inhalers, some of them decidedly complicated, 
have been devised for the administration of ether, but in the 
emergency cases that may fall to the nurse an improvised " cone," 
made of folded newspaper covered with a towel or muslin, will 
usually be employed. The cone may be put together with safety- 
pins or needle and thread, and the towel or muslin should cover 
it inside as well as out. It should be of such a size that it will 
fit snugly over the patient's mouth and nose, and its depth should 
be from six to seven inches. A piece of absorbent cotton or a 
crumpled gauze about the size of a lemon is placed inside the 
cone and saturated with ether, care being taken that it is wedged 
securely in the inhaler with sufficient space between it and the 
patient's face to allow free vaporization of the drug. 

The cone is now placed over the patient's nose and mouth, 
but a short distance away from her face to avoid the choking 
sensation caused by the too sudden exhibition of the anaesthetic 
in its full strength. 

As soon as the woman's throat and lungs have become ac- 
customed to the irritating action of the vapor, the cone is to be 
brought gradually towards her face until it fits over it snugly. 

The gauze or cotton inside the cone should be kept saturated 

with the drug, and for this purpose about a drachm of ether 

must be poured in every two or three minutes. In doing this 

the bottle or can is to be uncorked and the cone removed for 

10 



146 A NURSE'S HANDBOOK OF OBSTETRICS. 

an instant only, as the fresh ether is added, and replaced imme- 
diately over the face. A very few inspirations of air will be 
enough to delay the action of the anaesthetic materially. 

After five or ten minutes, and often when the patient seems 
to be passing quietly into a state of unconsciousness, she may 
suddenly begin to struggle violently and use all her strength 
to tear the cone from her face and get off the table or out of 
bed. This is due to the primary exhilarating effect of the drug, 
and is a condition to be watched for in every case. The patient 
is partly anaesthetized, as will be evident from her incoherent 
speech and unnatural behavior, and she must be securely held 
by assistants and fresh ether given freely until she becomes 
quiet again. 

The essential point in controlling the struggles of a par- 
tially anaesthetized patient consists in keeping all her limbs ex- 
tended at full length so that she cannot get a " purchase" on 
anything. Her arms must be held straight out at her sides, so 
that she cannot bend her elbows, and sufficient downward press- 
ure must be exerted just above her knees to prevent her drawing 
up her legs. 

At about this time the patient will often begin to vomit, and 
at the first sign of retching her head is to be turned as far as 
possible to one side to allow the vomited matter to escape from 
her mouth and prevent its possible entrance into the larynx. 
As this is done the lower jaw is to be drawn upward and for- 
ward as much as possible, and fresh ether must be administered 
freely, for the vomiting will stop as soon as the anaesthesia is 
complete. The mouth must be wiped out frequently with a 
towel, or with gauze or cotton in an ordinary sponge-holder, 
and care must be taken that the tongue is well forward and has 
not fallen back and occluded the throat. 

Complete anaesthesia will be attained in from ten to twenty 
minutes after beginning the administration of ether, and it is 
maintained by adding about a drachm of ether to the cone every 
four or five minutes. 

During ether narcosis the patient's face should be slightly 



ETHER. 



147 



flushed, but never pale or cyanotic; her respiration deep, pos- 
sibly stertorous (snoring), but never irregular; and her pulse 
full, of good quality, fairly rapid, but never intermittent. 

The nurse should not only watch the respiratory movements 
of the chest and abdomen, but make sure that respiration is 
properly carried on by noting that ether vapor actually escapes 
through the cone with each expiratory act. 




Fig. 59- — Administration of ether. Cone held snugly over face ; chin raised upward and 
forward and pulse taken at facial artery. 



As the patient's wrist is not usually within the reach of the 
anaesthetist, the pulse may be taken at the facial artery as it 
passes under the edge of the lower jaw at about the middle; at 
the temporal artery, just in front of the ear ; or at the posterior 
temporal artery, directly above the ear at the margin of the 
hairy scalp (Fig. 59). When, however, there is any doubt as 
to the character of the pulse taken at these points, it should al- 
ways be counted at the wrist as well. The open method of ad- 
ministering ether is simple and quite effective. A wet cotton 
sponge is placed on each eyelid and the eyes covered with a 



i 4 8 



A NURSE'S 1LAXDHOOK OF OBSTETRICS. 



folded towel. The Esmarch apparatus is used. A towel folded 
about its outer margin is brought around either side and crossed. 
This secures excellent results, as the ether may be slowly dropped 
without raising the cone. 

The danger signals in ether anaesthesia are a pallid or cyanotic 
face, irregularity or shallowness of respiration, and irregularity 
or extreme rapidity of pulse. 

In the majority of cases in which the administration of ether 
will fall to the nurse the physician will first anaesthetize the pa- 
tient himself, and whenever the nurse is in the slightest doubt 
as to the subsequent condition of the woman under operation, 
she should call upon the physician for assistance or advice with- 
out delay. A nurse should enhance every opportunity to perfect 
herself in the knowledge of anaesthesia ; if she has a rural prac- 
tice such knowledge is a rich possession. 

As soon as the baby is born, the nose and mouth cleared of 
all mucus, and the cord is tied and cut, the infant, wrapped in 
a warm blanket, is to be removed to a safe place, out of harm's 
way, and the nurse is to return at once to the assistance of the 
physician. From time to time, as opportunities offer, she should 
glance at the child to make sure that it is breathing properly, that 
the mouth and nose are free from mucus, and that there is no 
bleeding from the cord. Some obstetricians do not tie the cord 
at all, simply clamping it for one-half hour after it is cut. The 
nurse will do well to look carefully and incessantly after such 
cases. Again, many doctors tie the cord at the body junction, 
leaving only a small amount of tissue to retract. If the infant is 
well wrapped up and in a warm place it needs no further atten- 
tion until the placenta is delivered and the mother made entirely 
clean and comfortable. 

The after-birth is usually expelled in from fifteen to thirty 
minutes after the birth of the child, and the nurse must have 
ready for its reception a bowl or other sterile vessel covered with 
a warm bichloride towel, in zvhich it is to remain until it has 
been examined by the physician and he has given his consent 
to its destruction. The importance of this examination of the 



DELIVERY BY THE NURSE. 149 

placenta lies in the fact that it enables the physician to know 
if any part of it or of the membranes has been left behind in 
the uterus. 

The nurse will usually be called upon from time to time to 
relieve the physician in holding the fundus, and while she is 
so occupied he will doubtless take advantage of the opportunity 
to inspect the infant for deformity or malformation of any sort. 

Every moment that is not occupied with other matters is to 
be devoted to putting the room in order and making the patient 
clean and comfortable, so that the evidences of the labor may be 
gotten out of the way with as little delay as possible. 

Delivery by the Nurse. — In certain cases the nurse will find 
it necessary to manage the entire labor herself, either because 
of precipitate labor or through delay in securing the services of 
a physician. 

It is needless to say that such cases progress rapidly, and 
that almost before any careful preparations can be made the 
pains are recurring with such frequency and severity that the 
patient must be put to bed and given the undivided attention of 
the nurse. 

It seldom or never happens that the nurse and her patient 
are entirely alone, and usually the husband, some female relative 
or friend, or a servant can be called upon to place a small bowl 
in boiling water, cool quickly, add one bichloride tablet to one 
quart of water making a 1 : 2000 solution, or prepare some sort of 
an antiseptic solution, and place it on a chair or table by the side 
of the patient for the nurse's hands. The boric acid wipes for 
the infant's eyes and mouth can also be called for, and, as there 
is never any special hurry about tying and cutting the umbilical 
cord, there is usually time for the scissors and tape to be boiled 
in a shallow dish with just enough water to cover them. 

If the patient is fully dressed, as may be the case in precipi- 
tate labor, some one should take off her shoes and stockings and 
remove her clothing as rapidly as possible, but without any show 
of excitement, by cutting or ripping it if necessary. She should 
then be helped into a night-gown or, if this cannot be done, 



150 



A NURSE'S HANDBOOK OF OBSTETRICS. 



covered with clean sheets and blankets; and a pad or thickly 
folded sheet should be slipped under her buttocks in an effort 
tc protect the bedding and carpet from blood and other dis- 
charges. 

All these matters may be attended to by the direction of the 
nurse as she sits or stands by the patient's side and watches 
carefully the progress of the case, and if she keeps her wits 
about her and does not lose her head she will have no diffi- 
culty in securing an immediate mastery of the entire situation. 
She should leave some one in her place, carefully scrub her 
hands, use an antiseptic solution, apply her sterile gloves and 
gown. She should have these articles at hand not expecting for 
an instant to care for any patient without them. She may, if there 
is no time to scrub up, put on the sterile gloves. Even precipitous 
labor does not exempt a nurse from responsibility for results. 
She will, with cotton sponges, clean the external genitals care- 
fully, while clean towels placed under the buttocks and about 
the thighs will do much to prevent the possibility of infection. 

The room, the bed, and the patient are all to be prepared for 
the labor as carefully as the time will allow, and in those cases 
in which the nurse is called upon to conduct the delivery merely 
because of prolonged delay in the arrival of the physician, she 
will, of course, have everything in complete readiness. 

The nurse can deliver the patient and retain more freedom 
of movement if she is delivered on her side, lying on the left 
side along the right side of her bed. The nurse will sit on the 
bed, using her left hand between the limbs and her right free to 
apply solutions, sponge, etc. This is possible, because the pa- 
tient's legs are widely separated by two or more pillows folded 
and covered with a sheet. 

As the head comes down and begins to distend the perineum 
the nurse must watch it carefully, and prevent undue stretching 
of the parts by holding it back at the acme of each pain. This in- 
terference with the descent of the head to prevent its sudden ex- 
pulsion through the vulva and consequently laceration of the 
tissues may be kept up for fifteen minutes or more, or until the 



DELIVERY BY THE NURSE. 151 

parts are stretched to their utmost capacity and the head escapes 
in spite of every effort to hold it. The essential points are to 
delay the descent of the head until complete dilatation has taken 
place and to prevent its sudden delivery if possible and deliver 
the head between pains. If at any time faeces are expelled from 
the rectum the same should be deftly received in a towel and 
sponges and solution used skilfully. The nurse will then change 
her gloves and solution, arrange fresh towels, and proceed. This 
will occur less often if enemata have been properly given and ex- 
pelled, and infection so near the vulva at this time is fraught with 
great danger. 

If the membranes have not ruptured, they may, when the 
case is under the management of the nurse, be left intact until 
they appear at the vulva, resembling more than anything else 
in appearance the rounded end of a large bologna sausage. As 
soon as they protrude in this way and the nurse has convinced 
herself by careful examination that the presenting object is the 
amniotic sac filled with fluid, and not any part of the fcetus itself, 
the patient is to be informed of the nature and harmlessness of 
the discharge of waters which is about to occur and the sac is 
to be ruptured. This may be done easily and quickly by cutting 
through the tissue with the finger-nail at the height of a pain, 
and after a towel has been placed against the vulva to receive 
the gush of waters. 

As soon as the head is born the nurse should feel about the 
neck for the umbilical cord, and if it is found, it should be 
drawn gently to one side or the other until it can be slipped 
over the head. No force should be used in loosening the cord, 
for fear of injuring it and causing bleeding. 

The mouth, eyes, nose, and throat of the infant are now to 
be carefully cleansed from blood and mucus with boric acid 
solution, and the face must be held up so that it does not lie in 
the pool of blood and liquor amnii between the mother's thighs. 

There is no occasion whatever for haste in the delivery of 
the body, even if the face of the infant becomes distinctly cy- 
anotic, and the mother and others in the room may be assured 



[52 A NURSE'S HANDBOOK OF OBSTETRICS. 

that everything is satisfactory and that there is no danger or 
cause for alarm. In another moment the uterus will again con- 
tract and the body of the child will be expelled. 

If only the shoulders appear there is no harm in passing a 
finger, which has been carefully rinsed in the antiseptic solu- 
tion into the axilla and gently extracting the posterior arm. The 
body will now almost fall out of the vagina, and the infant is to 
be laid on its right side, between the mother's legs in a sterile 
towel to cover the cord, and covered with a warm woollen cloth 
or the nearest substitute for this which can be secured, pre- 
viously sterilized. 

If the child does not cry vigorously it may be spanked ener- 
getically but without too much force, or held up by its heels and 
slapped sharply on the back four or five times. If this is not 
successful, a little ice-water may be splashed briskly on its 
chest, but usually the slapping will suffice. In holding the baby 
up by its heels care must be taken that no traction is allowed to 
come on the umbilical cord. 

The instant the child is bom the nurse, or one of those pres- 
ent in the room, must place a hand on the patient's abdomen and 
grasp the fundus firmly (see Fig. 66), and this pressure is to 
be maintained without interruption for the next full hour, par- 
ticularly if there is the slightest tendency toward relaxation of the 
uterine muscles, or the face, pulse or other symptoms indicate 
possible hemorrhage before any is visible. As this is a very 
tiresome procedure, it is well for those having the matter in 
hand to relieve each other at fairly frequent intervals. The 
correct way to hold the fundus is described in detail. 

There need be no hurry about tying the umbilical cord, and 
the nurse may safely wait until the pulsations in it have ceased 
or grown very faint. The first ligature is to be placed about 
three inches from the infant's abdomen, to leave room for subse- 
quent tying in case of hemorrhage, and the second ligature two 
or three inches from the first. It is a good plan to tie a third 
tape around the cord, close to the vulva, to serve as a guide to 
the descent of the placenta. As the after-birth is forced out of 



TYING THE CORD. 153 

the uterus the cord will also escape from the vagina, and the 
progress of this expulsion can be estimated by watching this 
third ligature, which at the beginning was as close to the vulva 
as possible. 

The ligature should be tied with a " square knot " (Fig. 60), 
for the ordinary, or so-called " Granny " knot, will almost surely 





Fig. 60. — Square knot. 

slip, after a short time, no matter how tightly it may have been 
drawn when it was applied. The characteristic feature of the 
" square knot " lies in the fact that both ends pass under the 
same side of the loop, as shown in the figure, while in the 
" Granny knot " one end passes under and one over. If hemor- 
rhage occurs from the cord after it has been tied and the child 
dies or even is seriously weakened by loss of blood great blame 
will attach to the nurse, and it will be an extremely difficult mat- 
ter for her to free herself from the stigma of either neglect or 
incompetency. 

Consequently, the nurse who intends to practise obstetrics 
should make it a point to perfect herself in the method of tying 
a square knot until she can do so instinctively, and so avoid the 
possibility of any such accident as has been suggested. It will 
avail her nothing that the case was an emergency one and that 
she did her best under most trying and unusual conditions, for 
people who are desirous of having children allow nothing to 
escape the fury of their wrath if anything untoward occurs in 
the conduct of the case, and the fully trained nurse of to-day is 
regarded by many as the equal of the physician in technical skill. 

It is a very easy matter to learn to tie the square knot snugly 
and securely, and when this is done properly there will be no 
danger of its slipping or of secondary hemorrhage from the cord, 



154 



A NURSE'S HANDBOOK OF OBSTETRICS. 



except in the case of feeble or premature children in whom 
the tendency to bleeding is very great and who must always 
be watched with the utmost care. As many of the precipitate 
labors which will fall to the care of the nurse will be cases of 
premature birth, she must be extremely careful about tying the 
cord securely, and inspect it for hemorrhage at frequent in- 
tervals, tying it a second, or even a third time, if necessary. 

The cord must always be tied in two places and cut between 
the ligatures, for if this is not done and the case should chance 




Fig. 6i. — Granny knot. 

to be one of twins, the unborn child might possibly bleed to death 
from the maternal end of the severed cord. 

As soon as the cord is cut and covered with a sterile towel, 
the infant, wrapped in a blanket, is to be removed to a safe place, 
and the nurse should take charge of the fundus for a few 
minutes, at least, to make sure that it is hard and firm. If it is 
found to be soft and flabby vigorous kneading of the uterus 
should be practised until it again contracts properly. 

There need not be the slightest haste about the delivery of the 
placenta, and while it is usually expelled in from fifteen to thirty 
minutes after the birth of the child, no harm will result if it is 
delayed for an hour or more, provided there is no excessive 
bleeding. It is to be remembered that the uterus is resting during 
this period, and that when its muscular fibres have recovered 
from the exhaustion of the labor they will contract firmly and 
expel the after-birth. Under no circumstances should traction 
be made on the cord in an effort to pull the placenta out of the 
vagina, for this will probably result merely in tearing the cord 
from its attachment, while in rare cases, when the placenta has 
not entirely separated from the uterine wall, the womb itself may 
be dragged inside out, causing the condition known as inversion 
of the uterus. 



BREECH CASES. 



155 



In nearly every case, after a reasonable period of time, the 
woman will have another labor-pain and the placenta will appear 
at the vulva much like a miniature counterpart of the fetal head. 
It should be received in the palm of the hand and directed into a 
sterile bowl held for this purpose, and the string of membranes 
that trails behind is to be extracted with the utmost gentleness 
and deliberation, to prevent the detachment of any tags or frag- 
ments (Fig. 62). The method, formerly advised, of twisting the 
membranes into a firm cord by turning the placenta over and 




Pig. 62. — Delivery of placenta and membranes. (Bumm.) No traction should be used, but 
the membranes allowed to fall out of the vagina by their own weight. 



over on itself no longer meets with general approval and is not 
to be recommended. All that is necessary is to extract the mem- 
branes from the vagina slowly and carefully, taking plenty of 
time and using no force whatever. 

The placenta is to be preserved until the arrival of the physi- 
cian, in order that he may inspect it and make sure that it is 
intact. 

In precipitate breech cases, which occur when the infant 
is small or premature, there are two important points in the 
management which the nurse must not forget. 

Traction on the body, after it has passed through the vulva, 



56 



A NURSE'S HANDBOOK OF OBSTETRICS. 



must never be made, for it is essential to have the case progress 
as slowly as possible in order to secure complete dilatation of the 
parts and afford ample room for the passage of the head. 

Pressure must be made on the fundus as soon as the nature 
of the case is recognized, and maintained until the child is born, 
in order to prevent, if possible, the extension of the arms above 
the head. 




Fig. 63. — Delivery of the head in breech cases. The child's body is lifted up and back- 
ward over the mother's abdomen, and the head is pressed forward, so that the chin, mouth, 
nose, etc., will be successively delivered. 



The diagnosis of a breech presentation can often be made 
by the nurse, without vaginal examination and before the ap- 
pearance of the infant's buttocks at the vulva, by the escape of 
meconium in the vaginal discharge. 

As soon as the body is delivered to the level of the umbilicus 
the cord is to be secured and gently drawn down a few inches, 
to prevent traction on it when the head is born, and the extruded 



PRECIPITATE LABOR. 



157 



portion of the foetus is to be wrapped in warm towels, which are 
to be renewed as often as they become cool. This is necessary, 
not only to prevent chilling the infant, but to avert the danger 
of respiratory movements while the head is still undelivered, due 
to the shock of cold air striking the abdomen and chest. 

The downward pressure on the fundus in the direction of the 
axis of the pelvic brim is to be kept up, and, when the shoulders 
have escaped from the vulva, the arm which is the more easily 
reached is drawn out of the vagina by passing a finger over the 
infant's shoulder, down the arm to the elbow, and sweeping the 
forearm and hand across the face and chest into the world. The 
other arm is delivered in the same way, and then the body of 
the infant is raised upward and backward until it almost lies on 
the abdomen of the mother (Fig. 63) to favor the birth of the 
head. 

Unless the head can be delivered within five minutes after it 
has passed into the cavity of the pelvis the life of the child will 
be in great danger from pressure on the cord, and if there is 
any delay the nurse may pass one or two fingers into the child's 
mouth, and with those of the other hand under the symphysis 
pressing on the occiput, attempt to tip the head forward on the 
chest while the body of the infant is raised upward and backward 
and firm downward pressure is made by an assistant through 
the abdominal wall. 

Fortunately the cases of breech delivery that will fall to the 
care of the nurse are seldom attended with any great difficulties, 
for the very fact of their precipitate character presupposes a 
small child or a very large pelvis. The chief danger is extension 
of the arms above the head (Fig. 64), and this can often be 
avoided by the maintenance of firm pressure on the abdomen 
throughout the entire course of the labor. 

After the child is delivered the further management of the 
case does not differ from that of vertex presentation. 

Twins are not infrequently delivered precipitately on account 
of the small size of each infant, and unless they are " locked" in 
such a way that neither can be expelled without artificial aid 
(Fig. 65), twin births seldom or never give any trouble to the 



158 A NURSE'S HANDBOOK OF OBSTETRICS. 

medical attendant. As the babies are small, the first is delivered 
with very little difficulty, and the birth of the second is accom- 
plished with the utmost ease, because the passages are already 
dilated fully and there is nothing to interfere with its descent. 




Fig. 64. — Arms extended in breech delivery. The most serious complication that can arise 
in the extraction of the after-coming; head. 

None of the other abnormalities of position and presentation 
possesses any special interest to the nurse, for, unless they are 
of such a precipitate character that delivery is accomplished 
within a very short time, there will be ample opportunity to 
secure the services of some physician, even if the regular medical 
attendant cannot be reached. 

When the nurse finds, on her arrival, that the baby and pos- 
sibly the- placenta are born and lying in the bed, her first duty is 
to grasp the fundus with as little delay as possible and see if its 
contraction is satisfactory, and then make sure that the child is 
not lying face downward in the blood and discharges and in 
danger of strangling. As soon as the fundus is firm and solid 



PRECIPITATE LABOR. 



159 



the cord may be tied and cut and the infant turned over to some 
one who will wash its eyes and mouth and wrap it in a warm 
blanket. 




Fig. 65.— Locked twins. (R. Barnes.) First child partly born in breech presentation, the 
second lodged with the face under the chin of the first. 

In all cases of labor occurring in the absence of the physician 
the nurse must keep a cool head, for the patient and those about 
her are usually in a state of great excitement and turmoil, and 
this may be enough to cause relaxation of the uterus and trouble- 
some hemorrhage. 

A level-headed nurse, who shows no trace of nervousness or 
fear, can often change the entire picture in an instant and bring 
order and quiet out of chaos with a word and an air of authority 
and self-confidence. 



160 A NURSE'S HANDBOOK OF OBSTETRICS. 

Analgesia. — An obstetrician discovered chloroform and it 
was hoped that freedom from suffering at delivery had been 
found. Ether also offered relief. It has been seen that, in- 
telligently administered, they produce relief when suffering is 
at its keenest and may do no damage to mother or child ; but 
the search for a drug that would diminish pain without narcosis 
has gone steadily on. Whiskey, chloral, and morphine have been 
used for this purpose. A mixture of scopolamine and morphine 
had been used in psychiatry and surgery for years and was 
first used in obstetrics in 1903. This treatment was developed 
in some clinics abroad, and an elaborate technic devised by 
which it is claimed there is a disturbance of thought without loss 
of consciousness, secured by a combination of drugs adminis- 
tered in progressive doses as indicated by the patient's psychical 
perceptions. This was determined by tests, four in number, and 
has gained widespread publicity among the laity in America. 
Only the extreme popularity of this subject calls for its mention 
here. It is essential that a pupil nurse caring for such cases 
in a hospital obey instructions concerning discussions. 

From the graduate nurse on private duty intelligent replies 
are demanded. She is frequently asked, by patients who ap- 
parently have secured full information about the intricate de- 
tails, concerning her views and experiences, where such treat- 
ment may be secured, and its relative safety. If she is interested, 
and she should be, she will ask her doctor to inform her and 
refer her to some scientific literature. There is much con- 
troversy among obstetricians concerning its value, and a nurse 
displays ignorance who hastens to discuss an obstetrical ques- 
tion upon the basis of popular information. Her interest lies 
purely in the nursing of such cases. It may be said that any 
method that is safe for child and mother must surely come into 
general use, if at the same time pain and suffering are lessened 
to a greater degree than is possible with our present means. 
Dammerschlaf or " twilight sleep " requires conditions of pre- 
natal care, environment, psychical and physical conditions, and 
constant medical attendance, that make its widespread use a 
large question aside from all possible phases of danger (physical 



ANALGESIA. 



161 



and mental) to mother and child. Not enough is known of its 
relative value as yet, for a nurse to assume the responsibility of 
an argument in its favor or otherwise. Patients are to be met 
by no expression of opinion whatever from the nurse, and in 
this, as in every similar instance, they should be referred to 
their physician. 

The nursing is done under the constant supervision of a 
medical attendant. Every preparation must have been made 
according to routine technic. In addition there is a special en- 
vironment demanded which must be arranged. As the patient 
may not be intelligent, no adequate usual warning may be given 
of the stage of labor and especially close watchfulness is essential. 
The nurse may have the drugs to administer, scopolamine or one 
of its derivatives, morphine, codeine, pituitrin, chloroform or 
thyroid extract. She will prepare for probable forceps delivery 
and for the resuscitation of the infant from varying degrees of 
asphyxia. So far these cases have been nursed almost entirely 
under hospital conditions. 



XV 

The Management of the Puerperium 

The fundus uteri is to be held through the abdominal wall for 
one full hour after the birth of the child, if the uterus shows 
the slightest tendency to relax. This duty may be performed 
by the physician or he may delegate it to the nurse, but it must 
never be forgotten that it is of far greater importance than 
anything else that can be done at this time, and the nurse should 
never begin to put the room in order, bathe the patient, or wash 
the baby unless some one has a hand on the fundus. If this 
procedure were conscientiously and systematically followed out 
in every case, post-partum hemorrhage due to uterine inertia 
would be practically unknown. 

The nurse should sit or stand by the side of the patient, facing 
her feet, and the ulnar edge (the edge on the side of the little 
finger) of the hand nearest the patient is to be pressed down 
firmly on the abdominal wall in the median line and at a point at 
about the level of the umbilicus (Fig. 66). In the relaxed and 
flabby condition of the abdominal wall after the birth of the child 
it is quite possible to force it back until the backbone can be felt, 
and the nurse never should make the mistake of not using suffi- 
cient pressure. The uterus should now be felt below, and prac- 
tically in the palm of the hand, as a firm rounded mass about 
the size and shape of a large cocoanut. If the nurse does not find 
it at once she should feel around for it, for it may be displaced 
to one side or it may have relaxed until it has lost its firmness. 
If this rapid search fails to locate the fundus, she should call 
at once for the assistance of the physician, or, if she is alone, 
redouble her efforts, watch for hemorrhage as indicated either 
by the flow or by the patient's pulse and expression of counte- 
nance (pallor, etc.), and have some one give the woman one 
teaspoonful of fluid extract of ergot if it is to be had. The 
nurse herself should not remove her hand from the abdomen, 
and the vigorous kneading of the belly caused by her efforts 
162 



MANAGEMENT OF THE FUNDUS. 163 

to find the fundus, especially if assisted by the ergot, will usually 
be enough to make the uterus again contract firmly so that it 
can be distinctly felt under the hand. 

As long as it remains firm and hard it should be let alone, 
the hand resting against it with sufficient pressure to permit the 
immediate recognition of any tendency towards relaxation. 

From time to time this relaxation will occur and the uterus 
grow soft and slightly flabby, but still perfectly distinct to the 
touch. On these occasions the fundus should be grasped in the 
hand and " kneaded " with a rotary motion gently but with in- 
creasing force until firm contraction occurs and the uterus is 
again hard and solid. This manoeuvre is not at all unlike that 
often practised by patronizing adults when they grasp a small 
boy by the top of his head and while rumpling his hair in a most 
uncomfortable manner, and digging their finger-tips into his 
scalp, ask him, solicitously, what he is going to " be " when he 
is a man. 

As has been said, this attention to the fundus is to be kept 
up for one full hour after the birth of the child, by the end of 
which time the uterus will, in normal cases, have contracted 
firmly and permanently, and any further danger from hemor- 
rhage will be very remote. 

If, however, at the end of the hour the uterus is still relaxed 
and soft, and cannot be made to stay firmly contracted, the 
holding and kneading must be kept up until permanent contrac- 
tion takes place. If the delay is longer than two hours, it would 
be safer to notify the physician, even though the woman's gen- 
eral condition seemed to be good. 

As a rule, the physician prefers to attend to the fundus him- 
self for at least the first fifteen or twenty minutes, and this 
gives the nurse an opportunity to attend to the next most im- 
portant duty of the moment, which consists in " cleaning up " 
the bed and patient and making things as comfortable as possible. 
The worst of the blood and discharges should first be washed 
off with a towel dipped in warm bichloride solution (1 to 
1000). Next, the Kelly pad and everything under the patient 
are to be slipped out and into the pail at the side of the bed. 



I0 4 A CURSE'S HANDBOOK OF OBSTETRICS. 

A clean towel is now placed under the patient, a vulva pad 
applied temporarily, and she is covered with a clean sheet. The 
pail containing the Kelly pad and all soiled towels and other 
articles that may have been thrown in it or dropped on the floor 
are removed from the room, and already the most unpleasant fea- 
tures of the labor are out of sight. 

If the patient's night-gown has become soiled, it should be 
removed by cutting it down the middle in front and taking it 
off like a coat, for an attempt to bring it over the head will 
usually result most unpleasantly. If the patient objects par- 
ticularly to having it torn, it may be slipped off the shoulders, 
rolled down under the buttocks, and taken off over the feet, 
but the best and simplest plan is to tear it. As soon as it is 
removed a fresh warm one should be slipped over the head, on 
to the arms, and drawn down in front to cover the chest, but 
the back part of the garment is best left in a roll or soft pile 
under the shoulders or neck to avoid the possibility of its being 
soiled before the patient's back has been bathed, or if pajamas 
have been worn they are easily and quickly removed, and as 
two suits have been provided and both may not have been used 
during confinement, a fresh suit may be worn at this time. 

In like manner, if there are any stains of blood or other 
matter on the stockings, they should be removed, and fresh, 
warm ones put on. 

The nurse should now prepare a warm solution of tincture 
of green soap and, with fresh pieces of absorbent cotton care- 
fully wash off any blood or other matter that may be on the ab- 
domen or thighs, drying the parts immediately with a clean, soft 
towel. When this is done, the patient is carefully turned on one 
side and the process is repeated on the back, buttocks, and back of 
the legs. It may be necessary to turn the patient first to one 
side and then to the other for this purpose, and as the towel 
under her will by this time be soaked with blood, it is to be 
removed and a clean one put in its place, as well as a clean pad 
over the vulva. 

A woman after delivery is in great danger from an air- 
embolus. A patient wearing a proper binder and a snugly ap- 



THE PATIENT'S TOILET. 165 

plied perineal pad will be in less danger, particularly if, in ad- 
dition, the uterus is firmly held while she is moved. This pos- 
sibility exists only for a few hours and is possible through the 
introduction of a douche nozzle, from which air was not ex- 
pelled, and it is well for the nurse to exercise great care con- 
cerning the possible inrush of air into the uterus and its circula- 
tion. The doctor usually helps the nurse in the necessary mov- 
ing of the patient, as it is not possible for the nurse to do this 
alone. 

The patient is now returned to her back and preparations 
are made for cleansing the external genitals. This should be 
done according to the technic outlined under " Technic." From 
this time on it is by error in the nursing technic that infection 
may occur and it is a good plan to always adhere to one method. 

A sterile basin is to be placed against the vulva to receive the 
blood, and when everything is ready the person holding the 
fundus will draw the covering sheet out of the way, and the pa- 
tient is told to draw up her knees and separate them as far as 
possible. The hair covering the mons Veneris and vulva will 
be found matted together with clotted blood, and if it is at 
all abundant the greater part should be carefully cut away with 
scissors. The parts are then to be bathed with the utmost gentle- 
ness with the warm solution until every vestige of blood is 
removed and the parts are perfectly clean. The basin is now 
removed and a fresh vulva pad applied to take up the little 
stream of fresh blood that constantly trickles down over the 
perineum. This should be very quickly and efficiently done with 
no jarring of the patient. 

If the patient has been confined on a cot, the next step is to 
remove her to her bed. The bed should be warmed, except, of 
course, in summer, and on the draw-sheet is to be laid one of 
the " obstetrical pads " from the maternity outfit. If the patient 
is a large woman, and those who are to lift her are not very 
strong, it is better to move the cot up close to the side of the bed 
on which she is to lie ; she may then be lifted up by two persons 
(usually the physician and nurse) standing side by side. As 
soon as she is raised from the cot, a third person draws it quickly 



1(56 A NURSE'S HANDBOOK OF OBSTETRICS. 

out of the way and with one step forward her bearers place her 
gently in the bed and cover her with the bed-clothes. 

Unless a full hour after the birth of the child has elapsed she 
should not be moved except when the uterus is firmly contracted, 
and the fundus must be grasped again the moment she is laid 
down. During the brief interval required to change her from 
one bed to the other the unavoidable exertion to which she will 
be subjected will act as a sufficient stimulus to the uterine 
muscle to obviate the necessity of holding the fundus for a few 
seconds. 

If she is to remain in the bed in which she was confined, the 
next step after cleansing the vulva is to unpin and remove the 
white sheet and rubber sheet on which she is lying, leaving the 
bedding underneath fresh and clean. At the instant this is done 
an obstetrical pad is to be slipped under her buttocks to protect 
the draw-sheet and avoid the necessity of changing it for as 
long a time as possible. 

If the full hour for holding the fundus has not yet elapsed, 
and the nurse is not occupied with this matter herself, she is 
to put the room in order, as quietly, thoroughly, and expedi- 
tiously as possible. All soiled articles, basins, pitchers, and the 
like, are to be removed; towels, sheets, and other articles that 
are blood-stained are to be thrown into cold water, usually in 
the bath-tub with the water flowing in and out over them, until 
all stains are removed ; the physician's instruments are to be 
scrubbed with nail-brush, soap, and hot water, rinsed in fresh hot 
water, and dried thoroughly; and the furniture arranged prop- 
erly and with as little confusion as possible. The irrigator, 
if it belongs to the physician, is to be emptied, flushed out with 
hot water, and dried thoroughly, and the Kelly pad must be 
washed carefully with soap and hot water until it is absolutely 
clean, then rinsed quickly with scalding water and dried. The 
air-ring must not be emptied nor the pad folded up until it is 
absolutely dry, or its opposed surfaces will stick together and 
ruin it. 

By this time there will usually be no further need of hold- 



THE ABDOMINAL BINDER. 167 

ing the fundus, and the binder may be applied, so that the pa- 
tient may be left to herself and allowed to go to sleep. 

The function of the binder is often misunderstood by the 
laity, who are apt to suppose that it is used for the purpose of 
preserving the symmetry of the figure by preventing the lax 
abdominal walls from bulging outward. This is far from the 
truth, and in France, where women are supposed to be particu- 
larly solicitous as to their physical appearance, the obstetrical 
binder is not used at all. 

The objects of the binder are two: first, to prevent any 
tendency to hemorrhage by keeping up a firm and constant press- 
ure over the uterus; second, to make the woman comfortable 
by preventing cerebral anaemia, with its accompanying dizziness, 
headache, and, in some cases, even syncope. 

The causation of anaemia of the brain after labor will readily 
be understood when it is remembered that the walls, not only of 
the abdomen but of the abdominal blood-vessels, are lax and 
flabby after the comparatively sudden emptying of the cavity 
and the accompanying loss of from one to two pints of blood. 
To fill these empty vessels blood comes rushing in from other 
parts of the body, and unless they are subjected to the firm 
pressure of the binder, so much blood will be abstracted from 
other organs and tissues that the result, while not necessarily 
serious, is bound to be more or less uncomfortable to the patient. 

After about three days, when the balance of blood-pressure 
has again become established and the possibility of hemorrhage 
is past, the binder is no longer necessary, although the patient 
usually finds it very comfortable to wear it for a week or so more, 
and then to substitute an abdominal supporter, which she con- 
tinues to wear for another month, or until involution is complete. 

Acting on these principles, the author always insists on the 
use of the binder for the first three days. The perineal pad can 
be more snugly applied to an abdominal binder than a T, owing 
to the fact that it can be fitted closer around the groin and spread 
over a wider area in the back. This prevents an escape of the 
blood outside the pad. After this he allows the patient to de- 
cide for herself whether she wishes it used or not. 



I OS A NURSE'S HANDBOOK OF OBSTETRICS. 

The binder should be made of unbleached muslin, one and 
three-quarters yards long and three-quarters yard wide. The 
selvage may be torn off and the binder washed and ironed to 
make it soft and comfortable. Not less than six should be pro- 
vided, so that soiled ones may be changed as often as necessary. 
Binders should not be hemmed, as the hem is apt to cause un- 
pleasant pressure, but the edges may be " overcast " if desired. 
Binders of any other dimensions than those given are not desir- 
able, and those made of two thicknesses of cloth or in any way 
" fitted " to the body are very impracticable. In an emergency an 
excellent binder can be made of a piece of " roller " towelling cut 
the proper length. 

In applying the binder its purpose must be kept in mind and 
never overshadowed by efforts to gain an artistic effect in the 
arrangement of the pins. This is a common fault in the training 
that nurses receive in the wards, for not only is the strength and 
good nature of the private patient often exhausted by delay and 
fussiness in pinning up a binder, but the binder itself is seldom 
as snug at every point as it should be. 

In addition, the patient frequently succumbs to the enthu- 
siasm of the nurse and rather than disturb the work of art will 
spend considerable time in real discomfort, waiting to urinate, for 
instance, until the vulvar dressing is due, or for some other similar 
reason. Abdominal binders as ordinarily applied make beautiful 
photographs, but often are only a means of grace to the patient. 

The binder should be folded about half its length and slipped 
under the patient in the same way that a draw-sheet is changed. 
The ends are then held up in the air over the middle of the ab- 
domen and the binder drawn in one direction or the other until 
its middle is exactly under the middle of the patient's back, 
its lower edge well below the hips, and its upper edge at about 
the free border of the ribs. Beginning now at the lower edge, 
the two ends, held tightly together, are rolled up as firmly and 
as snugly as possible until the material at that point is as taut 
as it can be made. The pin is passed first through the roll and 
then through the single thickness of cloth on the side opposite 
the nurse and clasped. Beginning again a little above the first 



THE ABDOMINAL BINDER. 



169 




\, 






Fig. 67. — Abdominal binder. 



170 A NURSE'S HANDBOOK OF OBSTETRICS, 

pin the rolling is repeated in the same way and another pin 
inserted, and so on till all is done (Fig. 67). 

When at a point about the level of the umbilicus, a towel, 
rolled or folded to about the size of a large banana, may be laid 
crosswise of the abdomen under the binder, to cause extra press- 
ure on the fundus. A pin should be passed through the binder 
into the towel on either side to keep it from slipping. There is 
much danger that the towel may become displaced and harm 
ensue. This procedure must be done in the right way or not 
at all. 

The binder must be changed with sufficient frequency to 
keep it clean and comfortable at all times, and during the first 
two days this should be done as often as every four or five 
hours. Blood trickles down over the perineum and soaks into 
the binder behind, soon drying and becoming stiff and irritating, 
so that, no matter how clean and soft the front of the binder 
may be, frequent changes are none the less necessary. When 
the soiled binder has been removed the patient should be turned 
on her side and the buttocks bathed gently with soap and warm 
water and rubbed with dilute alcohol. The amount of comfort 
that this affords the patient well repays the slight trouble that 
it entails. Soiled binders are to be washed immediately after 
they are removed, and boiled and ironed before used again. 

The vulva pads must be changed at intervals of not less than 
every four hours, and, for the first day or two, fresh ones may 
be required as often as every one or two hours. If, for any 
reason, an apparently clean pad is taken off, it is never to be 
replaced, but a new one used in its stead. The reason for this 
absolute rule is because of the possibility of placing over the 
vulva that part of the pad which formerly was in direct con- 
tact with the anus. Soiled pads must be removed at once from 
the room and destroyed by burning. Under no circumstances 
should a pad be washed or otherwise cleaned (?) and used a 
second time. 

Every time a pad is removed the external genitals are to be 
bathed carefully and gently with warm green soap solution 
made up with boiled water. The nurse is to disinfect her hands 



REMOVAL OF VULVA PADS. 171 

and wear rubber gloves for this purpose, bestowing on them as 
much care as though she were going to make a vaginal examina- 
tion. Before the hands are disinfected the pad is to be unpinned 
and left loosely in position and a piece of paper laid on the 
floor to receive it. The dish containing the solutions and cotton 
sponges are to be placed on a chair or on the bed within 
easy reach, and, the parcel of clean pads is opened and laid in 
a convenient spot ; the forceps in a bottle of lysol, 2 per cent., 
in reach. 

After the hands are clean the soiled pad is removed with a 
thumb- forceps and laid quickly on the paper, out of sight of the 
patient, to whom its appearance is usually very unpleasant. The 
cleansing of the parts should begin with the separation of the 
labia majora with the thumb and forefinger of the left hand 
and the careful removal of any lochial discharge that may have 
accumulated in the creases of the vulva. This blood is always 
more or less irritating and tends to become dry in spots, which 
adds to the discomfort that it causes. In spite of this, the pa- 
tient often refrains from speaking of it, on account of her 
natural disinclination to require of the nurse duties which she 
knows must be of a somewhat repellant character. The nurse 
who will attend carefully to this little detail will find her efforts 
more highly appreciated than would seem to be warranted by 
the circumstance. This can all be done without variation from 
the sponge technic given under " Technic." 

After this has been done the external surfaces of the labia 
are carefully bathed from above downward, care being taken to 
remove every vestige of blood from the hair. If stitches have 
been inserted in the perineum the nurse must take pains not to 
let the cotton catch and pull on the free ends of the sutures, or 
she will cause the patient great pain. Sutures must always be 
carefully dried, and occasionally the doctor may order a dusting 
with aristol powder. But the nurse is never to apply boric 
acid or similar powder unless instructed to that effect. 

If any blood has collected on the buttocks and soaked into 
the back of the binder these parts must be made perfectly clean 
and the binder changed, as has already been said. 



172 A NURSE'S HANDBOOK OF OBSTETRICS. 

The pads and draw-sheet under the patient must be removed 
as often as they become soiled, but if the nurse is particular to 
change the pads frequently or to keep folded sterile towels over 
them, the draw-sheet will last for an entire day or possibly a 
little longer. As a rule, the draw-sheet is to be changed every 
twenty-four hours, and clean vulva pads must be provided 
at least as often as every four hours, and oftener if they are 
much stained, for even when they do not appear to be par- 
ticularly soiled they always contain, after a few hours, 
enough of the lochia to serve as an excellent breeding-place 
for bacteria. 

If the patient does not void her urine naturally within twelve 
hours after labor the bladder should be emptied with the cath- 
eter, and after this she is to be catheterized every six hours until 
the normal function of urination is re-established. 

Twelve hours is allowed in the first instance, because the 
relaxed condition of the bladder and abdomen after the removal 
of the pressure from the gravid uterus often permits consider- 
able distention of the bladder with urine before any desire to 
urinate manifests itself. Every effort should be made to avoid 
the use of the catheter, because of the danger of infecting the 
parts at the time of its introduction, and also on account of the 
fact that its use always tends to delay the time when natural uri- 
nation can be accomplished. Moreover, if the patient can once 
be induced to empty her bladder in the normal way, the subse- 
quent use of the catheter is almost never required. Conse- 
quently, at the end of the first twelve hours, and thereafter at 
intervals of six hours, efforts should be made to excite normal 
urination by the familiar methods of allowing water to run from 
a faucet, pouring water from one pitcher to another, directing 
a gentle stream of warm sterile water down over the vulva, or 
placing under the patient a bed-pan containing hot water and 
letting the steam from it surround the genitals, occasionally a 
warm saline enema will relax the urethra or some pungent smell- 
ing salts may provide the necessary stimulation. With some 
patients the mere presence of a second person in the room is 
enough to prevent urination, and, in such cases, the nurse should 



THE USE OF THE CATHETER. 173 

always leave the room on some pretext or other as soon as she 
has arranged the bed-pan, taking pains to tell the patient that 
she will not be back for a few minutes. Not infrequently, on 
her return she will find the bed-pan ready for removal. Per- 
haps the physician may order the patient to be helped to a sitting 
posture as there exists a strong prejudice against the catheteriz- 
ing, except as a, last resource, and he may prefer this to be tried 
if the patient is in good condition. 

If, however, all these efforts fail after a reasonable trial, the 
catheter must be used. This is an operation requiring great 
dexterity in the case of a woman recently delivered, for the 
parts are swollen and congested to such a degree that all the 
usual landmarks are distorted or temporarily destroyed. On 
several occasions the writer has been called upon to pass the 
catheter in the first day of the puerperium after nurses of long 
obstetric experience have failed utterly to find the meatus. The 




Fig. 68. — Glass catheter. 



best catheter for the purpose in hand is the ordinary glass one 
(Fig. 68) about six inches long and slightly bent at the tip. 

The soft rubber catheter, so often used in the belief that it is 
less liable to injure the delicate tissues of the parts, is not worth 
considering, for it possesses no advantages over the glass in- 
strument and is inserted with much greater difficulty. It is the 
only one, however, to be used during delivery, as the smooth 
glass catheter may break or injure the bladder. 

The preparations for using the catheter in private practice, 
where there is usually only one nurse on the case, are important, 
and must be carried out in detail to avoid the danger of infecting 
the patient. 

The catheter is to be boiled and the urine should be received 
in the basin used for boiling the instrument, or in a douche-pan, 
but never in a urinal which has to be placed in position after the 
nurse's hands are sterilized. 

The simplest, and therefore, the best, method is as follows: 



i; 4 A NURSE'S HANDBOOK OF OBSTETRICS. 

Boil the catheter in an agate basin of sufficient size to hold all 
the urine to be drawn oft" and with only enough water to cover 
the instrument. Prepare tincture of green soap solution and 
cotton sponges, and have a clean vulva pad within reach. Place 
a piece of paper on the floor to receive the soiled pad. As a 
lubricant for the catheter use white vaseline (in a tube) or, 
what is still better, any one of the preparations of Iceland moss 
lubricants which may be had of almost any druggist. Remove 
the screw-top and wrap the tube in sterile or bichloride gauze. 
Disinfect the hands, as before, with soap and hot water and 
bichloride solution, and after the patient has raised her knees 
and separated them as far as possible, take up the basin con- 
taining the catheter with a wet bichloride towel, pour off as 
much water as possible without spilling out the catheter and 
set the basin in the bed as close up to the vulva as possible. 
Remove the vulva pad with thumb-forceps and cleanse the parts 
thoroughly according to given technic. Then take up the cathe- 
ter, which by this time is sufficiently cool, squeeze on it some of 
the vaseline or other lubricant, and lay it back in the basin out 
of the water. (The basin can be tilted somewhat so that part 
of its bottom will be dry.) Now separate the labia as far as 
possible with the thumb and fingers of the left hand, until the 
opening of the meatus can be seen. Wipe off the tissues sur- 
rounding the urethral orifice with a clean cotton sponge dipped 
in the solution and, with the left hand still keeping the labia 
widely apart, pick up the catheter with the other and pass it, 
by the sense of sight, directly through the meatus into the bladder, 
taking every precaution not to let it touch any of the surround- 
ing parts (Fig. 69). 

The basin, if properly placed, will be near enough to the 
vulva to receive the stream of urine without any difficulty. 

When the bladder is empty, grasp the catheter between the 
thumb and second finger and press the forefinger firmly over the 
tip before withdrawing it (Fig. 70). When it is entirely out 
and over the basin the forefinger may be raised, and the urine 
within the tube will escape. This is a small matter of detail, but 
will often save soiling the bedding or the patient's clothing. 



THE USE OF THE CATHETER. 



175 



As has been said, every effort should be made to avoid the 
use of the catheter, and after the third day the patient may be 
allowed to sit up in bed to empty the bladder if the case is pro- 




Fig. 69. — Proper method of inserting catheter. The labia separated and the meatus 

exposed to view. 

gressing favorably. This, of course, should only be done with 
the consent of the physician, and the nurse should make sure 
that no ill effects follow the exertion. 

The patient's bowels should have been emptied by enema 





Fig. 70. — Method of withdrawing catheter. 



at the beginning of labor, and will not, as a rule, require any 
attention until the end of the second day. At this time the physi- 
cian usually orders a mild saline laxative, such as one-half of a 
bottle of the effervescent solution of the citrate of magnesia, at 



170 A NURSE'S HANDBOOK OF OBSTETRICS. 

night, followed by the other half in the morning, or castor oil ad- 
ministered in the least objectionable way, either with sarsaparilla, 
lemon or grape juice, whiskey or sherry wine, in bottom and on 
top of dose in glass. Lay ice upon tongue first and it is usually 
easily taken. 

If this is not successful, a soapsuds enema may be given in 
the middle of the forenoon, after waiting a reasonable time for 
the magnesia to act. If the progress of the case up to this time 
has been perfectly normal, there is usually no objection to letting 
the patient sit up on the bed-pan to empty the bowels, and if 
this can be allowed the enema is seldom required. The patient 
must be well supported by the nurse with the assistance of an 
abundance of pillows. 

After this the bowels are to be moved every second day by 
enema or otherwise, as the physician may direct, unless the 
natural efforts are effectual. The nurse must exercise care and 
skill when inserting the rubber rectal tube. Usually there are 
hemorrhoids and when perineal sutures are present, these must 
receive special care to prevent tearing. 

When the patient is on the bed-pan she is to be directed to 
hold the vulva pad closely against the vulva with her hand to 
prevent the entrance of fecal matter into the genital canal, and 
the nurse, in cleansing the parts, must be careful to follow the 
technic of sponging toward the rectum and discarding the 
sponges. 

It is needless to say that no vaginal douche should ever be 
given by the nurse except in compliance with the express direc- 
tions of the physician. If the lochial discharge emits a foul 
odor the physician may order a douche, but the matter must be 
left entirely with him. 

The irrigator and nozzle must be boiled before use, and the 
solution used for douching is to be made of boiled water always. 
The irrigator should hang about four feet above the level of the 
patient's bed, and the woman is to lie on a bed-pan covered with 
a sterile towel. A pillow should be arranged under the back and 
between the shoulders for support. 



TEMPERATURE AND PULSE. 177 

The nurse should cleanse the genitals as for catheterization 
and thoroughly irrigate the entrance to the vagina first. Then, 
changing the soiled tip for a clean one, she makes all necessary 
preparations of material and patient and then sterilizes her hands 
in the usual careful way. The greatest care must be taken, in 
inserting the nozzle, that it does not come in contact with the 
external surface of the body or with the hair covering the genital 
organs. She should hold the douche-tube in herrighthand, and 
with the fingers of the left separate the labia as far as possible 
so that the entrance to the vagina is clearly in sight. The tube 
can now be introduced into the genital canal without touching 
any of the external tissues, and the danger of carrying infection 
into the vagina is effectually eliminated. The physician will, of 
course, instruct the nurse as to the solution to be used for the 
douche and its temperature, but in the absence of any definite 
directions, as, for example, when he merely leaves word to the 
nurse while she is out, that the patient is to be douched, she may 
safely use two quarts of normal salt solution (two drachms to 
the quart) at a temperature of no° F. 

If a nurse makes a practice of doing all vaginal work about 
her patient wearing gloves and using a forceps in contact with 
sterile sponges and pads, she can be sure, if these articles are 
freshly boiled and sterile, that she will not infect her patient in 
that particular way. If she follows sponging technic outlined, she 
may be equally sure that she carries no infection into the uterus 
in that way. 

The temperature and pulse of both mother and child are 
to be taken every four hours during the first week and after- 
wards every night and morning unless the case is not doing 
well, when the four-hour record is to be continued. The tem- 
peratures of both patients are to be recorded on separate charts, 
to facilitate a clear understanding of the entire record at one 
glance. 

The public is so well educated in the matter of clinical ther- 
mometry that these charts must be kept out of sight of the 
mother from the very first, so that in the event of any unex- 
pected complication she will be ignorant of the amount of her 
12 



178 A NURSE'S HANDBOOK OF OBSTETRICS. 

fever and unsuspicious at the withdrawal of the chart from her 
daily inspection. 

A pulse of 100 or a temperature of 100. 5 F. is to be re- 
ported to the physician without delay, as either may indicate 
the onset of some serious disorder. 

Every attention must be paid to the comfort of the patient, 
for the more nearly normal her case, the more tedious is her 
confinement in bed while awaiting the involution of the uterus 




Fig. 71. — Proper method of introducing douche-tube. 

and other generative organs. She should be moved from one 
side of the bed to the other several times a day, and required to 
turn frequently from side to side after the first twenty-four 
hours. Her personal toilet must never be neglected to the slight- 
est degree, and her face and hands should be washed and her 
teeth brushed several times daily. Her hair is to be well brushed 
and combed night and morning, and this is most easily managed 
by doing it up in two braids, so that there will be no mass of 
hair directly at the back of the head. A warm general sponge 
bath with a little soap is to be given once daily, and this is of 
especial importance on account of the excessive perspiration that 



DIET IN THE PUERPERIUM. 179 

occurs during the puerperium. This bath is best given at night, 
just before the patient is ready to go to sleep, and but one part 
of the body should be exposed at a time. After the bath the 
entire body is to be rubbed with alcohol and water (equal parts), 
or, on account of the peculiar odor of the lochia, which is often 
quite distasteful to the patient, cologne or some favorite toilet- 
water may be used in place of the alcohol. It need not be said 
that the use of cologne or toilet-water must never be allozved to 
cover any laxity in the attention paid to the patient's toilet. 

The nurse must be quick to anticipate any and every need 
of the patient in the matter of her personal comfort, and never, 
under any circumstances, make it necessary for her to ask for 
attentions of this nature that should have been performed as a 
matter of course. 

The diet during the puerperium must be of a simple char- 
acter, but nourishing and sufficiently varied to please the appe- 
tite of the patient. In ordinary cases the following dietary will 
be all that is needed. 

First forty-eight hours: Milk (one and one-half to two 
pints a day), gruel, soup, one cup of tea a day, toast and butter. 

Second forty-eight hours : Milk-toast, poached eggs, por- 
ridge, soup, corn-starch, tapioca, wine-jelly, small raw or stewed 
oysters, one cup of tea or coffee a day. 

Third forty-eight hours: Soup, white meat of fowl, 
mashed potatoes, beets in addition to the above. 

After the sixth day return cautiously to ordinary light 
diet ; that is, three meals a day, meat of an easily digested charac- 
ter at one of them, such as white meat of fowl, tenderloin of 
beef, etc. Also a glass of milk three times a day, between meals 
and before going to sleep at night, and a glass in the middle of 
the night. Since the nurse will have had a more or less thorough 
course in dietetics, she will be able to give a rational reply to 
the objections that may be offered when upon the fifth day she 
gives her patient white meat of fowl or a broiled lamb chop. 
Eating meat of course will not cause fever, infection alone can 
do that ; but indigestion will result from over-feeding, as the 
patient has no great waste of heat and no energy is expended 
while she is quietly lying in a warm bed. 



igO A NURSE'S HANDBOOK OF OBSTETRICS. 

Rich, heavy foods throw too much waste upon the body. The 
old belief that foods, acid fruits particularly, will insure colic 
in the infant is now much discredited, though the mother's milk 
may excrete drugs and a few foods. The diet should consist as 
before stated of an easily digested and eliminated mixed diet, 
properly balanced to replace the waste and secretions as well 
as bodily heat. Under-feeding will decrease the amount of 
milk secreted in a marked way. Nourishing food with suffi- 
cient water, on the other hand, is efficacious occasionally in in- 
creasing the amount. 

Visitors should be excluded as far as possible during the 
first two weeks of the puerperium, and, as a rule, none but 
members of the immediate family should be admitted, and these 
for not more than five or ten minutes at a time. Friends and 
distant relatives are usually more interested in the baby than 
in the mother, and the infant prodigy may be exhibited for a 
brief interval to such callers in another room. The practice, 
common even among the better classes, of turning the lying-in 
chamber into a general meeting-place for conversation and 
gossip must be distinctly forbidden by the nurse. 

Flowers, so often sent in great profusion to the puerperal wo- 
man, may be shown to her as an evidence of the interest of her 
friends, but should be banished at once to the parlor or dining- 
room. A few flowers of faint and delicate odor may be placed 
at the side of the bed or on a table within her sight, but large 
bouquets of much fragrance are too overpowering for the good 
of the patient. 

The room is to be aired freely and with sufficient frequency 
each day to keep it fresh and sweet, for the lochia, the milk, the 
discharges of the infant, and the perspiration of the mother all 
tend to vitiate the atmosphere to a marked degree. In cold 
weather the patient is to be entirely covered with a sheet and 
blanket reaching above her head while the windows are opened 
for the purpose of ventilation. 

If the arrangement of the house permits, the nurse should 
always sleep in an adjoining room, to which she can take the 
baby for the night, and in which, in fact, the infant should spend 



TIME TO GET OUT OF BED. 181 

the greater part of its time. Under no circumstances should the 
nurse ever sleep with the patient, and if another room is not 
available she should be provided with a separate bed or cot. 

Unless the nurse is a very light sleeper, the patient should 
be given a small bell with which to call her when she is needed. 

The directions for the care of the infant and the management 
of its feeding are discussed elsewhere, and must be followed 
implicitly, and the nurse must keep a sharp watch for soreness 
or erosions of the nipples and report their occurrence at once 
to the physician. 

The time when the patient can get out of bed, or sit 
up in bed, is a question that always causes her great concern, and 
the nurse will do best to make no positive statement in this con- 
nection even in the most favorable cases. Physicians no longer 
observe any arbitrary rule in keeping a puerperal woman in bed, 
and each case must be decided on its own merits. 

As a rule, permission to sit up is granted when involution 
has progressed to such a point that the fundus uteri can no 
longer be felt above the symphysis pubis. Even this cannot al- 
ways be depended upon, and many factors may have to be con- 
sidered before a definite conclusion is reached. 

Generally speaking, women of the class likely to come under 
the care of the graduate nurse are required to spend two weeks 
in bed, one week on a couch or on the bed, gradually accustoming 
themselves to the use of an arm-chair, and one week up and 
about but confined to the same floor. After the fourth week the 
patient may begin to go up and down stairs slowly once or twice 
daily, but six weeks in all should elapse after the birth of her 
child before she can regard herself as entirely freed from all 
restraint. The fact should be impressed upon her that this pro- 
tracted period of non-exertion is not required because she is, in 
any sense, an invalid, but in order to permit involution to go on 
uninterruptedly. The idea is much the same as that which 
would hold in the case of a broken leg, where rest would be ab- 
solutely essential to perfect recovery, although the patient's gen- 
eral condition would be in no way affected. 



l82 A NURSE'S HANDBOOK OF OBSTETRICS. 

A doctor may order massage given in combination with pas- 
sive movements after the fifth day, to relieve the muscular in- 
activity, or he may prescribe exercises in bed for the patient. 
Some physicians lay great stress upon the manner in which these 
are carried out and give directions in detail. 

Nurses are more frequently called upon than is a masseuse 
and the application of this particular form of massage should 
be made familiar through practice. Whether massage is given 
or exercises practised, it is generally much enjoyed by the pa- 
tient, and the great prostration following the quiet of the pre- 
ceding ten or more days' confinement in bed is largely overcome. 



XVI 

Pathology of Pregnancy 

The disorders of pregnancy are, in many instances, merely 
exaggerated states of those conditions already described as being, 
in their milder forms, purely physiological and unavoidable. 
On the other hand, symptoms appear at times which must be 
regarded from the very moment of their onset as unnatural and 
pathological. The properly trained nurse should be able to dis- 
tinguish accurately between conditions which are mere exag- 
gerations of true physiological phenomena and those which are 
entirely pathological and inherently dangerous to the life or 
health of the patient. 

Nausea and vomiting, if occurring only in the morning and 
subsiding by about noon, so that during the latter part of the 
day the patient is able to enjoy and retain her food, are to be 
considered as physiological conditions, of importance only as 
they cause discomfort to the woman. However, about one- 
third of all pregnant women escape this, and it is believed much 
further relief could be afforded by the exercise of proper hy- 
gienic routine. A mental attitude that is absolutely healthy, 
fresh air and wide interest divert any morbid anticipations of 
trouble. This is the usual type of the " morning sickness " of 
pregnancy, and the patient is always able to assimilate enough 
nourishment each afternoon and evening to suffice for the entire 
day. In normal cases these symptoms should disappear en- 
tirely by about the middle of the fourth month, and they call for 
no medicinal treatment beyond the occasional administration of 
laxatives to keep the bowels in good condition. The nurse can, 
however, do much to make the patient comfortable and lessen 
the annoyance of morning sickness by giving a glass of hot milk 
or a cup of tea or coffee with toast or biscuits half an hour 
before the patient arises. This should be taken in the recum- 
bent position, and the woman should lie still on her back for a 

183 



184 A NURSE'S HANDBOOK OF OBSTETRICS. 

full half hour afterwards. When she attempts to arise she 
should do so slowly and gradually, avoiding any sudden change, 
to the upright posture. The morning vomiting almost never be- 
gins until the patient gets out of bed on her feet, and if the 
stomach can be induced to retain even a small quantity of food in 
the early morning it will usually continue to do so for the rest 
of the day. This simple procedure, coupled with careful atten- 
tion to the condition of the bowels, often affords great relief, and 
should always be given a fair trial. This vomiting or nausea, if 
once established, is difficult to overcome, and so it is specially de- 
sirable to prevent the first attack. 

In cases which prove more troublesome, without actually 
becoming serious, the writer frequently prescribes ten grains 
of sodium bromide dissolved in one tablespoonful of camphor 
water and given every three or four hours. This remedy is 
perfectly harmless in the proportions named, and while, as a 
rule, it is not wise for the nurse to order drugs on her own 
responsibility, there can be no objection to her availing herself 
of it in certain cases, as, for example, when she is travelling 
with a patient and no physician is obtainable. 

When, however, the vomiting persists throughout the entire 
day and into the night, so that the patient is not only unable to 
retain any nourishment whatever, but loses her sleep as well, 
the condition is wholly different and becomes distinctly patho- 
logical. Such women lose flesh and strength and quickly be- 
come emaciated to a startling degree. As the condition ad- 
vances they develop fever, the so-called " starvation tempera- 
ture," and unless relief is afforded promptly they lapse into 
the typhoid state and die of exhaustion. This is, of course, 
an extreme type, and one that will rarely be encountered, but 
the passage from the harmless form of vomiting to the variety 
that may properly be termed pernicious is very insidious, and 
the nurse must constantly be on the alert lest her patient retain 
too little nourishment and so begin to lose flesh and strength. 

As a safe rule of guidance, the nurse should regard with 
suspicion any vomiting that persists beyond the noon hour, and 
report the fact to the physician. 



NAUSEA AND VOMITING. 185 

The treatment of the more severe forms of morning sickness 
lies, of course, with the medical attendant, but the nurse must 
never forget that the whole affair is of nervous origin and that 
it is extremely detrimental for her to express before the patient 
the slightest evidence of apprehension as to the prospect of its 
ultimate control. So strongly does this psychical factor enter 
into the causation of the vomiting of pregnancy of whatever 
type, that it is not unusual for the mere entrance into the pa- 
tient's room of an eminent consulting physician to bring about an 
immediate cessation of the symptoms. 

The vomiting centre in the brain along with the brain tissue 
is hypersensitive and suffers from the general poor circulation. 
This has been likened by some obstetricians to a condition re- 
sembling chronic shock. All the factors entering into the causa- 
tion of vomiting in pregnancy are still matters for research, but 
a poor circulation and its effect upon the brain is one generally 
accepted. It follows logically that proper clothing and elimina- 
tion may combat the condition. 

In severe cases all feeding by mouth is usually stopped and 
rectal medication and alimentation substituted. For drugs, nerve 
sedatives of the bromide class are usually ordered, and nutrient 
enemata should consist of peptonized milk, egg-nog, liquid pep- 
tonoids, panopepton, or matzoon. 

These patients are usually sent to a hospital for treatment, 
as the definite routine necessary for their control can be best 
carried out and the psychical neurotic condition be best met. 
The family are rarely of much assistance in carrying out the 
doctor's treatment and unless this is strictly adhered to, the ner- 
vous condition may not be successfully combated. 

Before the administration of a nutrient enema, the rectum 
should be thoroughly washed out with a hot normal salt solution. 
This not only cleanses the canal and favors absorption, but the 
salt solution itself is taken up in considerable quantity, supplying 
fluid to the tissues and relieving the distressing thirst from 
which the patient always suffers. Not more than eight ounces 
of nourishment should be used at each feeding, and it should 
be at the body temperature and injected very slowly and as 



iS6 A NURSE'S HANDBOOK OF OBSTETRICS. 

high up in the canal as possible, preferably in the colon itself. 
As a rule, the rectal feeding should not be given oftener than 
twice daily, and once in every six hours is the extreme limit. 

Exclusive rectal alimentation can never be continued with 
safety for more than two weeks, and if by that time the vomit- 
ing has not been controlled to such a degree that the stomach 
will retain at least part of the required nourishment, the physi- 
cian is justified in adopting more radical measures, which usually 
consist in the prompt termination of the pregnancy. 

There is, unfortunately, a class of women who understand 
full well that the last resort in the treatment of the pernicious 
vomiting of pregnancy is the induction of abortion, and who, 
in their anxiety to avoid having children, deliberately keep up 
and aggravate their symptoms by the surreptitious self-ad- 
ministration of emetics. Happily, such women are not often en- 
countered, but the nurse as well as the physician must always be 
on guard against the successful practice of such criminal im- 
position. 

Many other methods of treatment have, of course, been ap- 
plied from time to time for the control of the vomiting of preg- 
nancy, and even such a simple procedure as elevating the pa- 
tient's buttocks to a level above that of her head has been known 
to succeed, but in general any marked vomiting should be re- 
ported promptly to the physician and the treatment left in his 
hands. 

Occasionally the doctor will relieve the stomach of the accu- 
mulation due to vomiting and retching, by lavage. The reversed 
peristalsis results in a condition making this often a great re- 
lief to the patient. Occasionally it has an excellent tonic effect 
upon her nervous system. This hyperemesis gravidarum rarely 
lasts more than three weeks and, if controlled, recovery is gen- 
erally rapid. 

Almost every drug in the Pharmacopoeia has been suggested 
at one time or another as a specific in this condition, but the fact 
remains that no definite plan of action can be outlined to fit all 
cases, and treatment that proves almost miraculously success- 
ful in one instance will, and often does, fail utterly in another. 



CONSTIPATION. 187 

With the general health, and especially the bowels, in good con- 
dition, the next most important factor in treatment is to gain 
the entire confidence of the patient and imbue her mind with the 
idea that the condition is only temporary, and that it will surely 
be controlled in due course of time. Above all else, the subject 
of vomiting must never be discussed, or even mentioned in the 
presence of the patient, for the mildest and most well-inten- 
tioned inquiries of relatives at the breakfast table will not in- 
frequently precipitate a severe attack of vomiting that might 
otherwise have been avoided altogether. In like manner the 
patient should never be asked what she would like to eat, or if 
she feels inclined to partake of food, and the nurse must use her 
wits and ingenuity to learn the caprices of her patient's appetite, 
so that she can, without comment of any sort, place before her 
at proper intervals daintily prepared and tempting dishes. 

It is to be distinctly understood that any vomiting persisting 
after the fifth month may be of serious import, and that this 
statement applies especially to that which makes its initial ap- 
pearance in the latter half of pregnancy after the ordinary 
" morning sickness " of the early months has ceased. Any such 
late return of vomiting, however slight, should be reported at 
once to the medical attendant, for it is usually due to some form 
of general constitutional poisoning, known as " toxaemia " and 
is often the forerunner of eclampsia. 

Constipation is the usual condition of the bowels during 
pregnancy, and is due largely to impaired peristaltic motion of 
the intestine caused by pressure from the gravid uterus. The 
nurse should see that at least one satisfactory movement occurs 
daily, and, as a routine, it is well to have the patient drink a 
glass of hot water for this purpose each morning before break- 
fast. The water should be as hot as can be borne, and a pinch 
of salt may be added to give it a taste. In the chapter on the 
Management of Pregnancy, a number of routine suggestions are 
made, which, if followed, will materially aid in preventing con- 
stipation from becoming uncontrollable. Proper elimination can- 
not be too clearly insisted upon, and here daily, normal hygienic 
habits prove their priceless value. 



1 88 A NURSE'S HANDBOOK OF OBSTETRICS. 

This simple treatment, combined with a largely farinaceous 
diet, is occasionally all that is necessary, but usually some simple 
laxative is required in addition. The best preparation in such 
cases is the fluid extract of cascara sagrada, given at bed time in 
doses of one-half to one teaspoonful. If the bitter taste of the 
plain fluid extract is objectionable to the patient, the aromatic 
extract may be given instead, but it will be necessary to adminis- 
ter the later preparation in about double the dosage. Starting with 
half a teaspoonful of the fluid extract (or one teaspoonful of the 
aromatic extract), either pure or in water as the patient prefers, 
the dose may be increased or diminished from night to night until 
the amount necessary to secure one daily evacuation is ascer- 
tained. 

In addition to this nightly medication, an occasional glass of 
Hunyadi water may be given before breakfast, and at times a 
soapsuds enema will be indicated. Preparations containing aloes 
in any form should be avoided lest they tend to aggravate the 
existing tendency toward hemorrhoids. 

Under no circumstances should the patient be overdosed with 
cathartics, and the physician should be consulted if the constipa- 
tion does not yield readily to some such simple plan of treat- 
ment as the one outlined above. 

Diarrhcea occasionally occurs during pregnancy, and its 
onset should be reported at once to the medical attendant. If it 
is allowed to persist it may result in a miscarriage, either be- 
cause of severe straining efforts at stool or on account of an ex- 
tension of the existing intestinal inflammation. 

Castor oil, so commonly given at the onset of a simple diar- 
rhcea, cannot be allowed during pregnancy except by direct order 
of the physician, for it is to be remembered that the abortifacient 
properties of the drug are so well marked that they have earned 
for it the unenviable name of " the poor woman's ergot." 

Dyspncea (difficult breathing) occasionally results from 
pressure on the diaphragm of the pregnant uterus, and may 
be sufficient, in the last weeks, to interfere considerably with 
the patient's sleep and general comfort. It is not a serious 
condition, but, unfortunately, it cannot be wholly relieved until 



VARICOSE VEINS. 189 

after the birth of the child, when it will disappear spontaneously. 
It is most troublesome when the patient attempts to lie down, 
and her comfort may be greatly enhanced by propping her well 
up in bed with pillows and cushions. In this semi-sitting pos- 




Fig. 72. — Varicosities of the lower extremities. (Bumm.) 



ture she will at least sleep better and longer than with her head 
low. 

Varicose veixs may occur in the lower extremities (Fig. 
72), and at times extend up as high as the external genitals or 
even into the pelvis itself. A varicosity is an enlargement in the 
calibre of a vein due to a thinning and stretching of its walls, and 
may be compared roughly to the bulb in the middle of a David- 



190 A NURSE'S HANDBOOK OF OBSTETRICS. 

son syringe. These distended areas occur at short intervals 
along the course of the vessel, and give it a knotted appearance. 
They are caused by pressure in the pelvis from the enlarged 
uterus, which presses on the great abdominal veins and inter- 
feres with the return of the blood from the lower limbs. Added 
to this primary cause, any debilitated condition of the patient 
favors the formation of varicosities in the veins because of 
the general flabbiness and lack of tone of the tissues. 

Naturally, the greater the pressure in the abdomen the 
greater will be the tendency to this complication, so that in 
twin pregnancies or in cases of contracted pelvis, where the 
gravid uterus is relatively much larger than normal, varices 
are very frequently seen. Also any occupation which keeps 
the woman constantly on her feet in the latter part of preg- 
nancy causes an increase in abdominal pressure and so acts 
as an exciting factor. The most marked case of varicosities 
ever seen by the writer was in the case of a woman who kept 
a small bakery and luncheon-room and attended to her duties 
in the shop up to the hour of her confinement. 

The first symptom of the development of varices is a dull, 
aching pain in the limbs due to distention of the deep vessels, 
and inspection will show a fine purple net-work of superficial 
veins covering the skin like lace. Later, the true varicosities 
appear, usually first under the bend of the knee, in a tangled 
mass of bluish or purplish veins often as large as a lead-pencil 
and suggesting a strong resemblance to a bunch of fish worms. 
As the condition advances the varicosities extend up and down 
the limb along the course of the vessels, and in severe cases 
affect the veins of the labia majora, the vagina, and the uterus. 

The treatment consists first and chiefly in the prompt 
abandonment, at the beginning of pregnancy, of garters, cor- 
sets, and all other articles of clothing that can cause pressure 
at any part of the body. If varicosities develop in spite of this 
precaution, the patient should spend a good part of the time in 
the recumbent position, and when she is on her feet the legs 
should be bandaged firmly from the ankles to the hips or fitted 
with elastic stockings. Where the general condition of the pa- 



I9i 

tient is below par the physician will prescribe iron or some other 
suitable tonic. Constipation is, of course, to be avoided, as an 
overloaded state of the bowels adds to the existing abdominal 
pressure. Every effort should be made to prevent the develop- 
ment of varices, for if they are once formed they never disappear 
entirely. In slight varicosities covering small areas, strips of 
adhesive plaster applied over the distention will often relieve the 
condition ; but care must be taken not to encircle the leg. 

Hemorrhoids (piles) are nothing more than varicosities of 
the veins about the lower end of the rectum and the anus, and 
the little lumps and nodules seen in a mass of hemorrhoids are 
merely the distended portions of the affected vessels. Like 
varicosities in other places, they are due to pressure interfering 
with return venous circulation, and are aggravated by consti- 
pation. They often cause great distress to the patient, and 
their prominent symptom is a constant and painful desire 
to empty the bowel, which is called " rectal tenesmus," and is 
not relieved, but more often increased, by straining efforts at 
stool. 

The treatment consists in relieving the constipation, in the 
use of hot compresses, and in the application of an ointment 
containing gallic acid, which can be obtained of any druggist, 
without a prescription, under the name of " nut-gall ointment." 
If these measures are not successful the case should be referred 
to the physician, who will doubtless prescribe suppositories con- 
taining opium or morphine. 

(Edema (swelling) of the lower extremities is not of im- 
portance unless it is associated with albuminuria. If it causes 
much discomfort it may be relieved by rest in bed, and the 
wearing of a proper abdominal binder. When the swelling ex- 
tends to the hands or face it is to be regarded with great sus- 
picion as a possible forerunner of eclampsia, and the appear- 
ance of oedema in any part of the body should serve as an in- 
dication for the immediate examination of the urine. 

Irritability of the bladder, characterized by frequent and 



n)2 A NURSE'S HANDBOOK OF OBSTETRICS. 

often painful efforts at urination ("vesical tenesmus"), may 
occur at any time during pregnancy, but is usually most trouble- 
some in the later weeks. The knee and chest position or the 
Sims position will sometimes afford relief. If it cause great dis- 
comfort it should be reported to the physician, who may be able 
to relieve it by the correction of an abnormal position or presen- 
tation of the foetus or by the administration of vaginal sup- 
positories containing opium or belladonna. 

Anaemia, of mild degree, is the normal condition of the blood 
during pregnancy, but at times it becomes sufficiently severe 
to call for the most active treatment. 

In such cases the onset is usually gradual, and unless the 
patient is carefully watched her condition will become truly 
alarming before treatment is begun. 

The symptoms of severe anaemia usually begin with head- 
ache, and the face becomes colorless and puffy. QEdema of 
the lower extremities begins and gradually ascends until it 
covers the entire body, and may even invade the serous cavities. 
The patient now loses flesh and strength rapidly, and suffers 
from sleeplessness, dizziness, headache, dyspnoea, and frequent 
attacks of fainting. 

The treatment, of course, rests entirely with the physician, 
although the nurse can do much to prevent the occurrence of 
this severe type of anaemia by keeping a careful watch over the 
patient's general condition and encouraging her to exercise 
freely in the open air throughout the entire period of gesta- 
tion. 

No woman who sleeps well, has a good appetite for nourish- 
ing food, assimilates properly what she eats, and spends a fair 
portion of the time out of doors is in any danger of becoming 
markedly anaemic. 

Diseases of the heart, and especially affections of the 
mitral valve, are greatly aggravated by pregnancy, and their 
fatal termination is often hastened from this cause. 

If the patient has placed herself under medical care at the 
beginning of gestation, and if the physician has made a proper 
and thorough examination of all her organs at this time, he will 






PTYALISM. I93 

be in a position to administer such treatment as may be neces- 
sary. The only thing the nurse can do, when it seems to her 
probable that the heart is affected, is to report the matter at 
once to the medical attendant. Personally, the writer believes 
that these patients should not be allowed to go on in the preg- 
nant state, but that abortion should be induced at the earliest 
opportunity after a positive diagnosis has been made. 

Ascites {dropsy) may affect the extremities and even invade 
the pleural and peritoneal cavities. It is due to the altered 
condition of the blood, and the treatment, which should be 
wholly in the hands of the physician, consists mainly in the 
relief of the anaemia, the administration of diuretics, rest in 
bed, and milk diet. 

Ptyalism, or salivation, while one of the rarer complications 
of pregnancy, is most annoying to the patient and very stub- 
born in responding to treatment. It is due entirely to altered 
enervation, and is characterized by an enormously increased 
secretion of the saliva. Women have at times been known 
to discharge as much as two quarts of saliva daily from this 
cause. 

Associated with ptyalism is occasionally seen an excessive 
secretion of tears, and the face becomes swollen and eczematous 
from being constantly bathed in moisture. 

This complication, if it occurs at all, usually appears in 
the early months of pregnancy, and, fortunately, is inclined to 
cease spontaneously. It is seen in highly nervous women of 
low vitality and is apt to cause great mental depression and 
interfere with nutrition. 

The treatment should be relegated to the physician, and con- 
sists in building up the general health with iron and arsenic and 
in the use of astringent mouth-washes accompanied by atropine 
and bromides, or chloral internally. The treatment is very 
unsatisfactory and the condition is a most disagreable one, not 
only for the patient, but for the physician and nurse as well. 

Insomnia often proves troublesome, and is best relieved by 
strict hygienic methods, open-air exercise, and massage, sup- 
plemented by alcohol rubbing after the patient has retired for 
13 



1 94 A NURSE'S HANDBOOK OF OBSTETRICS. 

the night. The sleeping- room should, if possible, be large and 
well ventilated, and so situated that the patient will not be sub- 
jected to any disturbing influences. 

If these measures do not enable her to secure a proper 
amount of natural and refreshing sleep the physician should 
be consulted, and will doubtless order trional, sulfonal, or some 
similar drug. Under no circumstances should opium or mor- 
phine ever be administered in these cases. 

Palpitation of the heart and syncope (fainting) are of 
no consequence unless it can be shown that they are associated 
with, and due to, some organic disease. As a rule, they are 
purely neurotic manifestations, and usually occur in the early 
part of a first pregnancy, and when the patient is in a hot, 
crowded, and badly ventilated room. 

Neuralgia and headache occurring during pregnancy 
should be carefully investigated by the physician, and the nurse 
is to be cautioned against the indiscriminate use of the various 
popular remedies for these conditions. 

Neuralgia, if facial, may be due to affections of the teeth, 
which require the attention of the dentist, and headache, while 
possibly of purely nervous origin, may be a symptom of severe 
constitutional disease. 

In any event, it is safer for the nurse to refer these appar- 
ently trivial symptoms to the medical attendant than to attempt 
their treatment herself. 

Paralysis occurs in certain cases, and may appear either 
before or after delivery. It may be due to uraemia, to cerebral 
congestion, or even to purely neurotic causes. Fortunately its 
outcome is usually favorable, and the treatment, of course, rests 
entirely with the physician. 

Cough, unless due to a distinct bronchitis, is ordinarily of 
reflex origin and is unimportant. In the last months of preg- 
nancy it may be due to direct pressure of the gravid uterus. 

Leucorrhcea ("whites") occurs frequently in pregnancy, 
especially if the patient is debilitated and anaemic, and is char- 
acterized by a more or less profuse mucous discharge from the 
vagina. It is often relieved by hot vaginal douches of a solu- 



PRURITUS. 195 

tion of borax (one tablespoonful to the quart), given twice 
daily, — night and morning. The patient should lie on her back 
while taking the douche, so that the solution will reach every 
part of the vaginal canal, and at least two quarts, as hot as 
can be borne comfortably, should be used. 

The nurse must keep in mind, however, the possibility of 
irritating the uterine muscle to contraction by the use of the 
douche and so causing a miscarriage. This is not likely to 
happen unless the douche is too hot or administered with too 
much force, but at the first appearance of pain, or even " bear- 
ing-down" sensations in the lower abdomen the irrigation should 
be discontinued at once, the patient kept quietly in bed, and the 
matter reported to the physician without delay. If this treat- 
ment is not successful, he may find, on examination, erosions of 
the cervix or other causes sufficient to keep up the discharge. 

Pruritus (itching), when confined to the neighborhood of 
the vulva, is usually due to a coexisting leucorrhoea, and dis- 
appears when the leucorrhoea is cured. It may be relieved by 
hot applications or by the use of some preparation containing 
naphthol, such as " resinol ointment." 

When the pruritus is general and covers the entire body it 
is almost always neurotic in character, though it may be due 
to a gouty diathesis or to diabetes. The treatment in such cases 
should be in the hands of the physician, and usually consists 
of rest in bed, regulated diet, the use of bromides in large doses, 
and the practice of thorough cleanliness, which applies to all 
degrees of pruritus, however slight. If the patient is gouty 
or is suffering from diabetes, these conditions will, of course, 
receive appropriate treatment. 

Chorea, popularly known as " St. Anthony's," " St. John's," 
or " St. Vitus's" dance, is, fortunately, one of the rarest com- 
plications of pregnancy, for it is one of the most serious. It 
usually occurs in the early months of first pregnancies in very 
young women, though it may develop at any time. As a rule, the 
history will show that the patient has suffered previously with 
the disease. 

It may begin suddenly or insidiously, and is characterized 



196 A NURSE'S HANDBOOK OF OBSTETRICS. 

by involuntary movements, or twitchings, of the arms and legs, 
which gradually become more and more marked and extended 
to other groups of muscles. There are exacerbations and remis- 
sions of the disease, and the movements regularly cease during 
sleep, to reappear again when the patient awakes. When the 
disease develops early in pregnancy the patient usually aborts, 
and in many cases it is necessary to induce abortion in order to 
save her life. 

Any symptoms suggesting chorea should be reported to the 
physician without delay. 

Displacements of the uterus may be of old standing or 
may occur after pregnancy is established. The symptoms of all 
types of displacement are practically the same, so far as the nurse 
is concerned, and consist chiefly in marked irritability of the 
bladder, excessive constipation, pains in the back and loins, and 
a feeling of weight and " bearing down " in the pelvis. Any 
such combination of symptoms should be reported promptly to 
the medical attendant, in order that he may correct the mal- 
position before the pregnancy is too far advanced. 

Albuminuria, complicating pregnancy, may be one of 
several types, and may occur as early as the third month, al- 
though it usually makes its first appearance at about the sixth 
month. 

The diagnostic and only positive symptom is, of course, the 
presence of albumin in the urine, which should be discovered 
by the physician in the course of his regular urinary examina- 
tion. The analysis must be a careful one, including a micro- 
scopic examination for casts, etc. In properly conducted cases, 
where analyses of the urine are made systematically and at 
stated intervals, the discovery of albumin will be made before 
any other marked symptoms develop, and it often happens that 
suitable treatment can be instituted with sufficient promptness 
to ward off the impending attack. Hence it is of the utmost 
importance for the nurse to attend carefully to the collecting of 
specimens of urine at regular three-week periods, and forward- 
ing them to the physician for analysis. If unchecked, the wastes 



ECLAMPSIA. 197 

increase in amount' and a group of certain symptoms show- 
ing the general toxaemia develop with rapidity. 

In neglected cases the patient becomes anaemic, suffers from 
headache, which is chiefly frontal, and develops oedema, first of 
the ankles and legs, and later of the face and upper extremities. 

This oedema involves the internal organs as well, the cir- 
culation being .directly affected by the accumulation of waste in 
the kidneys. The patient may suffer from this condition in the 
lung. Ringing in the ears and dizziness soon become annoying 
symptoms, and disturbances of sight, such as double vision and 
the appearance of spots floating before the eyes, occur and in- 
crease as the albuminuria becomes more marked. In severe 
cases actual blindness may occur. 

The urine becomes high-colored and scanty and the pulse is 
hard, small, and rapid. 

Vomiting persists throughout the entire day, and is especi- 
ally significant in women whose ordinary " morning sickness " 
has ceased. 

In this disturbed state of the digestive system a slight attack 
of acute indigestion or the occurrence of any other ordinarily 
trivial disorder is enough to precipitate an eclamptic seizure. 
A woman in such condition is on the very brink of disaster, and 
the nurse should send at once for the physician, and while 
awaiting his coming put the patient in bed, in a dark quiet room, 
keep her body warm and give her water to drink freely. Put her 
on an exclusive diet of skimmed milk and move the bowels 
freely with dessert-spoonful doses of a saturated solution of 
Rochelle salt, given every fifteen minutes until free catharsis is 
established. 

Eclampsia is a disease of pregnancy characterized by the oc- 
currence of convulsions resembling somewhat those of epilepsy, 
and appearing, usually, late in pregnancy just at the onset of 
labor. It may develop, however, at any time during the last three 
months of utero-gestation, during labor itself, or, rarely, after 
labor has taken place. 

The exact cause of eclampsia is not definitely understood, 
but it is safe to say that it is largely dependent upon deficient 



i S A NURSE'S HANDBOOK OF OBSTETRICS. 

elimination of waste products from the maternal organism. 
Many theories are advanced. According to one theory the liver 
and kidney disease is caused by the toxaemia which is due to 
an auto-intoxication from wastes not eliminated ; according to 
another these poisons are due to the metabolic changes going 
on in the foetus in utero or due to poisons developed in the in- 
testinal tract. Its threatened onset is indicated by the presence 
of albumin in the urine, by insufficient excretion of urea, or by 
both of these symptoms together. 

The premonitory symptoms are those which have just been 
described as characteristic of albuminuria. 

Eclampsia is very dangerous to the mother and child, and 
these facts are all the more lamentable when it is remembered 
that, under proper management and with careful attention to 
diet and urinary examinations, the disease should be a wholly 
preventable complication. 

Carelessness in the management of pregnancy and neglect 
of the necessary urinary analyses are, unfortunately, so much 
more often the rule than the exception that, although the writer 
has never lost a mother from eclampsia in his own practice, 
he knows of no less than eight deaths from this cause alone, 
and within the past six years, among his own circle of friends 
and acquaintances. Of these, one woman was a physician her- 
self, and another, the mother of several children, had suffered 
from marked premonitory symptoms of eclampsia in all of her 
previous pregnancies, in spite of which no urinary examinations 
whatever were made by her physician and no special diet or 
treatment was given her. 

Such lack of management is nothing less than criminal, and 
the writer hopes and believes that no reader of this book will 
allow any pregnant woman, no matter how well she may appear 
to be, to go through her pregnancy without proper urinary 
analyses, at least during the last three months. 

After the woman has suffered from albuminuria, and has 
shown its characteristic symptoms for a varying period, she 
may, if the case has not been treated, have a miscarriage. This 
seems to be an effort on the part of nature to relieve her con- 



ECLAMPSIA. 199 

dition, for by the death of the child and its expulsion from her 
body the strain on her eliminative organs is lessened at least 
to the extent that she no longer has to excrete the waste prod- 
ucts of the foetus. More frequently, however, even if the child 
dies and an attempt at miscarriage occurs, she will pass into 
the eclamptic state and have the characteristic convulsions of 
the disease. 

One attack is practically like another. The patient first 
complains of dizziness, and then everything grows black before 
her eyes. Her hands are clinched, with the thumbs drawn in ; 
her head is drawn backward or to one side ; her face is deathly 
pale ; the corners of her mouth are drawn down, and the eyes, 
open but rolled upward so that only the " whites " are visible, 
give to the countenance a particularly ghastly appearance. Now 
the large vessels in the neck begin to pulsate violently, the face 
grows gradually more and more cyanotic until it becomes almost 
black, and the glottis closes, causing respiration to stop. 

In this condition the woman remains for from ten to twenty 
seconds, in a state of complete rigidity, after which, if death 
does not occur, her muscles gradually relax. Respiration now 
becomes rapid; she froths at the mouth, and may expel some 
blood if she has bitten her tongue; her arms and legs begin to 
twitch, and soon her entire body is in a state of violent con- 
vulsion. After three or four minutes this gradually ceases and 
the woman passes into a condition of coma, from which she 
emerges in a few minutes with no distinct recollection of what 
has taken place. In severe cases the coma may grow deeper 
and deeper until death occurs, or she may pass directly from 
one convulsion to another without regaining consciousness be 
tween the attacks. These convulsions resemble the uraemic con- 
vulsions due to kidney disease and found independent of preg- 
nancy. 

If the nurse first sees a patient on the occasion of the occur- 
rence of an eclamptic convulsion it will be necessary for her to 
make a diagnosis of the cause of the spasm, in order that she 
may proceed intelligently. 

Practically the only conditions that might be confused with 



200 A NURSE'S HANDBOOK OF OBSTETRICS. 

eclampsia arc epilepsy and hysteria, and if the following points 
are borne in mind the nurse will have little difficulty in arriving 
at a correct opinion. 

Eclampsia occurs in a woman who is pregnant at least six 
months. She has suffered during her pregnancy from the symp- 
toms of albuminuria. Her face is swollen and her entire body is 
cedematous and puffy. Her friends will tell of her headache, 
vomiting, visual disturbances, and the like, and often inquiry will 
reveal the sad fact that her physician (if she has one) has not 
made any urinary examinations or ordered any special diet for 
her. 

Her urine will be scanty and highly colored, and if a little 
is placed in a teaspoon and boiled over the flame of a match 
or gas-jet it will turn white and often solid from the coagula- 
tion of albumin. This test is simple, quick, and absolutely con- 
clusive, for, w T hile there may have been little or no albumen in 
the specimen prior to the onset of the attack, it is sure to be 
present in large amount before many convulsions have occurred. 
The author can see no objection to the nurse's availing herself 
of this means of diagnosis unless the physician is close at hand 
and his presence can be secured without delay. If he has to 
be summoned from a distance, a positive report as to the highly 
albuminous state of the urine might be of value to him in making 
his preparations for the treatment of the case, w r hile such knowl- 
edge would certainly aid the nurse in her management of the 
patient while awaiting the arrival of the medical attendant. As 
she comes out of one convulsion she may pass almost at once 
into another, and, even without a thermometer, it will be evi- 
dent that she has considerable fever. She may have only one 
or two attacks and die, or miscarry and recover, or she may 
have fifty or sixty at intervals of from a few minutes to a few 
hours, any one of which may prove fatal. 

Epilepsy occurs independently of utero- gestation, and if the 
woman chances to be pregnant it is merely a coincidence. The 
convulsion is generally ushered in with an outcry, and after it 
is over the patient passes into a sound sleep which may last 
for an hour or more. The attack will not be repeated for days, 



HYSTERIA. 20I 

at feast, and often it will be weeks or even months before another 
seizure occurs. There are none of the premonitory symptoms 
of albuminuria, and the history will show that the patient has 
long been subject to similar attacks. The nurse must, of course, 
be on her guard against those rare cases in which eclampsia 
occurs in a patient known to be an epileptic. The history of the 
albuminuria and the time of the attack (during the last three 
months of pregnancy), together with the recurrence of the con- 
vulsions at short intervals, the appearance of the patient, and 
the presence of fever, should be enough to settle the question. 

Hysteria, like epilepsy, occurs independently of pregnancy, 
and if it happens that the woman is pregnant the hysterical 
attack may occur at any period of gestation. The convulsion of 
hysteria is not as severe as that of epilepsy or eclampsia, the 
patient never loses consciousness completely, fever is not present, 
and the pulse and respiration are normal or nearly so, and the 
urine, instead of being scanty, concentrated, highly colored, and 
albuminous, is pale, of low specific gravity, and excreted in large 
quantity. 

It is, of course, to be understood that any convulsion occur- 
ring during pregnancy is a sufficiently important matter to war- 
rant the nurse in sending at once for the physician, and if the 
immediate services of the regular medical attendant cannot be 
secured she should lose no time in summoning the nearest avail- 
able practitioner. 

The treatment of eclampsia begins primarily with those pre- 
ventive measures which should be instituted by the physician 
as soon as the pregnant woman comes under his professional 
care. These consist largely in the adoption of a proper hygienic 
regime which provides for a nourishing diet with the reduction 
of meat to once daily, the careful regulation of the bowels, 
the practice of daily bathing to keep the skin in good working 
order, the indulgence in regular out-of-door exercise, and the 
daily ingestion of at least two quarts of pure water to act as a 
diuretic and otherwise " flush out " the system. When these 
measures are carefully followed, and the urine is examined at 
stated intervals for evidences of albuminuria, it should always 



202 A NURSE'S HANDBOOK OF OBSTETRICS. 

be possible to avert a threatened eclamptic attack. Unfortu- 
nately, this plan can be put in operation only when the patient 
comes under observation at a comparatively early period of 
pregnancy, and in many cases the nurse will not be called to a 
case until shortiy before labor. 

Her first duty, under these circumstances, will be to ascertain 
if the patient's pregnancy has been properly managed and if the 
necessary urinary examinations have been made. This inquiry 
can always be conducted in a tactful way that will cast no reflec- 
tion on the behavior of the attending physician, and if the nurse 
finds that the proper precautions have not been taken she is 
perfectly justified in making such suggestions as may be indi- 
cated concerning diet, exercise, and the like, and in securing a 
specimen of urine and sending it to the physician for analysis. 
Moreover, during the last two months of pregnancy, she should 
send a specimen of urine once a week to the medical attendant, 
whether it is asked for or not. This should be done entirely 
as a matter of course, for, in the light of modern obstetrics, no 
physician would dare to find fault with such a procedure, even 
if he belonged to that happily small class of men who do not 
bother to make urinary analyses at these times. If the patient 
shows any general symptoms of threatened eclampsia, such as 
headache, visual disturbances, severe vomiting, and marked 
oedema, the physician should be sent for at once and his atten- 
tion explicitly directed to her condition. 

Occasionally the nurse will encounter the patient for the first 
time when she is in a convulsion, or the woman will have an 
eclamptic seizure shortly after the nurse's arrival or at some 
other time when there is no physician at hand. 

After sending at once for the nearest medical man and as- 
suring herself, from the character of the convulsion, the history 
of the case, the bloated appearance of the patient, and the al- 
buminous state of the urine, that the attack is really due to 
eclampsia, the nurse may proceed as follows until assistance 
arrives. Let the patient be lifted without jar into a warm bed ; 
insist upon absolute quiet in the room and the avoidance of all 
excitement ; no anaesthetic must be given by the nurse. No 



HYSTERIA. 203 

matter what the first cause, the kidneys are almost without ex- 
ception involved and chloroform has been shown to produce very 
serious toxic effects upon the liver of mother and child. The 
liver has the work of breaking up poisons preparatory to their 
excretion by the kidneys. Ether, with as large an admixture of 
oxygen as possible, may be ordered to control the typical convul- 
sions. Remove all the patient's clothing, cutting the garments with 
scissors, and wrap her entire body (arms and legs separately) 
in a hot wet pack and cover her with warm blankets; empty 
the bladder with the catheter, disturbing the patient as little as 
possible ; as soon as she can swallow give two drops of croton 
oil in one teaspoonful of sweet oil, if it can be obtained ; whether 
the croton oil is given or not, make a saturated solution of Ro- 
chelle salt and give a dessert-spoonful every fifteen minutes until 
the bowels move freely. Prepare saline solution for intravenous 
injection or hypodermoclysis, as these are usually demanded. 
Oxygen is often given with excellent effect upon the cyanosis 
and respiration. When the convulsion ceases insist upon ab- 
solute quiet, and do not allow so much as a whisper in the room ; 
disturb the patient as little as possible and only for the necessary 
purposes mentioned above. The time to treat this culmination 
of symptoms known as an eclamptic convulsion is before the 
toxaemia has developed to this alarming stage. The tongue must 
be protected from being bitten by placing a spoon or clothespin 
covered with a cloth or napkin to prevent damage to the teeth 
themselves. This must be within instant reach to be of use. The 
nurse will, of course, remove all false teeth. If convulsions con- 
tinue uncontrolled, the child is usually born. If alive, tie and 
cut the cord and remove it to another room ; if it is dead, leave 
it alone, to avoid disturbing the patient, but in any case keep 
a hand on the fundus, under the hot pack, as a preventive 
against hemorrhage. If there is bound to be a considerable 
delay in securing the attendance of a physician, get thirty grains 
of chloral hydrate and forty grains of sodium bromide and give 
it by rectum. Beyond this : 
Darken the room. 



204 A NURSE'S HANDBOOK OF OBSTETRICS. 

Maintain absolute quiet. 

Keep up the hot pack. 

Keep ice-bag to head and throat. 

Observe closely to prevent burns from external heat applied. 

Do not disturb the patient under any circumstances. 

Secure medical aid as soon as possible. 

Wait till the physician arrives before doing anything else. 

Do NOT LOSE YOUR HEAD. 

As the patient is unconscious or much dazed, the nurse must 
not leave the irresponsible woman alone and must be able to 
secure and maintain the absolute quiet prescribed. 

Upon the doctor's arrival he may hasten to empty the uterus 
if this has not already occurred and the nurse must make the 
necessary preparations, or he may adopt elimination and seda- 
tives as he sees fit. The effect of these sedatives, given usually by 
rectum must be very carefully observed. Morphine or veratrum 
viride may be ordered. 

Hemorrhage from the uterus may occur at any time during 
pregnancy, and while it may be due to high arterial tension or to 
erosions or ulcers of the cervix, and so be of no special con- 
sequence, it may, on the other hand, be of serious import; and 
all attacks of bleeding should be reported at once to the physi- 
cian. 

In the early months of pregnancy hemorrhage may be due 
to a beginning abortion or the case may be one of ectopic gesta- 
tion. In the later months the bleeding may indicate placenta 
praevia or be due to the separation of a normally situated pla- 
centa from the uterine wall. These four conditions will be 
described in detail later on, but so far as the nurse is concerned 
the general treatment of hemorrhage occurring during pregnancy 
is the same in every case : send at once for the physician ; put 
the patient in bed and make her lie still on her back ; elevate her 
bed at the foot ; reassure her in every way possible, and avoid 
all noise and every suspicion of excitement on the part of her 
friends and relatives ; if she is very nervous or if the hemorrhage 



ECTOPIC PREGNANCY. 205 

seems at all severe, give one-sixth grain of morphine hypo- 
dermically. 

If the bleeding continues, a sharp watch must be kept for 
symptoms of acute anaemia, and it may be necessary to send for 
the nearest physician available instead of waiting for the arrival 
of the regular medical attendant. When the blood escapes into 
the bed, as in the case of placenta praevia, the amount of the 
flow should be enough to indicate the proper course to pursue, 
but it must be remembered that in certain instances, as, for 
example, when a normally situated placenta becomes detached 
from the uterus, the woman may bleed to death inside of her 
own body and little or no blood escape from the vagina. In 
such a case the symptoms indicative of danger would be those 
of severe hemorrhage from any other cause. 

The patient would be pale, and her pallor would increase as 
the bleeding continued ; she would be extremely nervous and 
restless, and her face, bathed in a cold sweat, would have an 
anxious and " wild" expression ; her pulse would grow more 
and more rapid and feeble, and finally would disappear entirely 
at the wrist ; her thirst would be extreme, and she would soon 
complain of ringing in the ears, dizziness, spots before the eyes, 
and at last total blindness ; towards the end would be seen that 
horrible condition known as " air hunger," in which the patient 
literally tries to bite the air as she would a solid substance, so 
great is her need of oxygen. 

Under these circumstances the nurse can do nothing beyond 
getting medical aid as soon as possible and preparing for the 
probability of a surgical operation, with plenty of hot water and 
hot, sterile, normal salt solution for infusion. 

Pain in the region of the uterus may be merely neuralgic in 
character and of no consequence beyond the discomfort that it 
causes, but its occurrence should always be reported to the 
medical attendant, as it is one of the symptoms of abortion, of 
ectopic gestation, of concealed hemorrhage, and of many of the 
diseases that may complicate pregnancy, such as appendicitis 
and various other disturbances of the abdominal organs. 

Ectopic gestation, occasionally and incorrectly termed 



20 6 A NURSE'S HANDBOOK OF OBSTETRICS. 

" extra-uterine pregnancy," means, literally, a pregnancy that is 
" out of place." In the chapter on Fetal Development it was 
said that the ovum is usually impregnated by the male element 
while it is still in the Fallopian tube, after which it passes on into 
the uterus. If, now, anything occurs to prevent its passage into 
the uterine cavity, it will either develop where it is or else, in 
very rare instances, fall out of the open trumpet-shaped end of 
the tube and develop in the cavity of the abdomen. If its prog- 
ress towards the uterus were not interfered with until it reached 
that portion of the tube which lies within the uterine wall, it 
would be in the uterus, although decidedly ectopic or " out of 
place," which explains the incorrectness of the general term 
" extra-uterine pregnancy." 

This accident may be caused by a narrowing of the tube due 
to a constriction within itself; to folds or twists of the tube 
which may be the result of accident or disease ; to pressure from 
pelvic organs or tumors ; or it may occur with a very long tube 
or when the impregnation takes place close to the ovarian ex- 
tremity, so that before the ovum reaches the uterus it has 
developed to such a size that it is too large for the canal through 
which it is supposed to travel. 

In any event it becomes firmly lodged at some point and 
development proceeds, up to a certain stage, as though it were 
safe within the uterine cavity. 

The most common form of ectopic gestation is that which 
goes on in the tube itself, and is called " tubal pregnancy" (Fig. 
73) ; the next most frequent type occurs in that portion of the 
tube which lies within the uterine wall, and is termed "inter- 
stitial pregnancy;" and the rarest form of all is known as " ab- 
dominal pregnancy," in which the ovum develops in the abdomi- 
nal cavity. Neither tubal nor interstitial pregnancy ever goes on 
to the full development of a living child, but occasionally, when 
the ovum falls into the cavity of the abdomen, the placenta 
attaches itself to some viscus and the foetus develops to full 
term and is removed by abdominal section. 

In all cases of ectopic gestation the woman exhibits, to a 
certain degree, the usual early symptoms of pregnancy, and, as 



ECTOPIC PREGNANCY. 



207 



a rule, regards herself as being normally pregnant. The uterus 
enlarges somewhat, the irritability of the bladder and the breast 
symptoms appear, and the patient suffers more or less from 
" morning sickness." Her menstruation may cease entirely, but 
there is usually a slight flow at each monthly period due to con- 
gestion of the lining membrane of the uterus. This may be only 
enough to stain the napkin for one day, and although such a 
" show" may occur in the early part of a normal pregnancy, it 
is entirely unnatural and sufficiently suspicious to warrant the 




Pig. 73. — Ectopic gestation. Tubal variety, ruptured at the end of the third month. 
A, uterus from behind with several small fibroid tumors in its wall; B, right ovary; C, 
ruptured tube ; D, left ovary; E, foetus. 

nurse in sending for the physician or at least advising him of 
its appearance. 

As the ectopic gestation advances there will be considerable 
pain of a sharp, shooting character on the side of the affected 
tube and extending down the leg. This pain is due to the 
stretching of the tissues of the tube or uterine wall, and any such 
combination of pain and slight bleeding should be brought to 
the notice of the medical attendant without delay. 

In abdominal pregnancy the condition may not be recognized 



2oS A NURSE'S HANDBOOK OF OBSTETRICS. 

until the case has gone on to full term, when, as labor does not 
occur, a careful examination will disclose the true state of affairs. 
In unrecognized abdominal pregnancy the child will die, and 
may cause death of mother from peritonitis, or it may become 
mummified and remain in the belly indefinitely or else adhere to 
the abdominal wall and later slough out as an abscess. 

Cases of tubal and interstitial pregnancy, unless recognized 
and operated upon, will rupture into the abdomen sooner or later 
(usually between the first and third months), and the patient 
may bleed to death or die of peritonitis or shock. 

A ruptured ectopic sac would be diagnosed by the history of 
the early symptoms of pregnancy, the excruciating pain at the 
time of the rupture, the occurrence of collapse, and the rapid 
onset of signs of severe internal bleeding. 

The nurse can only send at once for surgical aid, lower the 
patient's head, elevate the foot of the bed, keep the patient 
surrounded with hot packs and perfectly quiet, and prepare for 
an abdominal section. 

While it is possible that the hemorrhage will stop and the 
products of conception be absorbed, bleeding is usually severe, 
and only the most energetic action saves the life of the patient. 

Placenta previa (Fig. 74) signifies an attachment of the 
placenta directly over, or in the immediate neighborhood of the 
cervix instead of at its usual site near the fundus of the uterus. 
When the placenta completely covers the internal os the condi- 
tion is known as " central placenta prcevia; " when merely the 
edge of the placenta extends over the opening it is termed "mar- 
ginal placenta prcevia; " and when the placenta is simply attached 
low down on the uterine wall, near the os but not overlapping it, 
it is called " lateral placenta prcevia." 

In any case the condition forms a distinct obstruction to de- 
livery, and the first symptom is a sudden discharge of bright red 
blood without any pain and apparently for no particular reason. 
The first hemorrhage is rarely fatal, but any subsequent one may 
result in the death of the mother before any surgical assistance 
can be obtained. At the first appearance of bleeding of this 
character the nurse should send the patient to bed, give one- 



PLACENTA PREVIA. 



20Ci 



sixth grain of morphine hypodcrmically, summon the physician, 
and prepare for an immediate operative delivery, — usually a ver- 
sion. It is needless to say that all preparations for labor should 
be made without the patient's knowledge, to avoid the possi- 
bility of causing her any alarm. 







Fig. 74. — Placental attachment. A, normal attachment at the fundus; B, lateral placenta 
praevia ; C, marginal placenta prsevia; D, complete, or central, placenta praevia. 

Hemorrhage due to the detachment of a normally situated 
placenta may show itself externally or it may be entirely con- 
cealed, the blood remaining in the uterus and finding room for 
itself by collecting between the fetal sac and the uterine wall (see 
Fig. 74). In such a case the only symptoms would be those of 
severe internal hemorrhage already described, together with 
excruciating pain located at the point of placental separation. 

These cases of concealed hemorrhage are often very difficult to 
14 



210 A NURSE'S HANDBOOK OF OBSTETRICS. 

diagnose, but the nurse would at least know that something 
serious was the matter, and in putting the patient to bed, giving 
morphine for the pain, and sending at once for the physician she 
would relieve herself of further responsibility. The symptoms 
of concealed hemorrhage from placental separation are practi- 
cally the same as those caused by rupture of the uterus, but when 
it is remembered that the placental detachment always occurs 
before, and the rupture of the uterus during, labor, it will not 
be a difficult matter to distinguish between the two conditions. 

Nose-Bleed occasionally occurs late in pregnancy or early 
in labor, and is due to the existing hydremic condition of the 
blood, coupled with a congested state of the nasal mucosa. It 
is seldom troublesome, but, in certain rare cases, it proves very 
intractable, and may persist until the patient loses an alarming 
quantity of blood. Such cases are, of course, very unusual, 
but the possibility of their occurrence should be kept in mind, 
and any profuse hemorrhage from the nose should be reported 
to the physician. 

Slight hemorrhages from the stomach or lungs, also due to 
the existing hydremia and from areas of local congestion, are 
occasionally met with late in pregnancy, and, unless it can be 
shown that they are due to other causes, such as a gastric ulcer 
or pulmonary tuberculosis, they are seldom of any moment. 
They are, however, usually more alarming to the patient than 
would be a really serious nose-bleed, and, of course, they should 
be reported to the medical attendant at once. While awaiting his 
arrival or advice the patient should lie quietly on her back and 
take small bits of cracked ice at frequent intervals. 

The eruptive fevers, when affecting a pregnant woman, 
are always exceptionally severe, and if the temperature is at all 
high, abortion or miscarriage is almost certain to occur. 

Scarlet fever is particularly fatal during pregnancy, and 
very little hope can be offered to the woman who contracts the 
disease at this time. 

Pneumonia in pregnancy is usually very fatal to both mother 
and child, although, when abortion occurs, as it often does, the 
maternal chances are somewhat improved. 



SYPHILIS. 211 

Tuberculosis shows apparent improvement during preg- 
nancy, but its fatal outcome is probably hastened, for the woman's 
decline is usually very rapid after the birth of the child. 

Malaria is very apt to cause abortion, either by reason of 
its high temperature or because of the large doses of quinine 
given for its control. It must be said, however, that physicfans 
practising in malarial districts give quinine to pregnant women 
without any regard to its oxytocic properties, and claim that 
under these conditions — that is, when given to a pregnant woman 
who is actually suffering from malaria — it has no tendency to 
cause miscarriage. In any event, the physician is between two 
horns of a dilemma when he encounters severe malaria com- 
plicating pregnancy, for if quinine is not given, through fear of 
causing abortion, the high temperature of the disease will most 
probably do so. 

Syphilis is the most common cause of all abortions, and a 
syphilitic patient should be under active treatment from the very 
beginning of gestation is she wishes to be at all certain of going 
to term and giving birth to a living child. The nurse should 
remember that syphilis is often encountered where it is least 
expected, and that her professional acquaintance with the disease 
will by no means be limited to her hospital training. 

Syphilis is defined as a chronic, infectious disease (which 
may also be hereditary, inducing cutaneous and other lesions), 
due to a specific germ the Treponema pallidum. 

The primary or first stage is marked by chancre and indolent 
bubo. This may appear almost anywhere and need not be of 
venereal origin at all. 

The secondary or second stage is characterized by skin erup- 
tions, glandular swellings, and mucous patches. These two 
stages are highly infectious, and follow each other within two or 
three months. 

The tertiary or third stage is marked by gumma and severe 
skin lesions. The gumma attests the degree of damage suffered 
by all tissues of the body. It develops after a lapse of years. 

Syphilis is curable and Osier and Churchman state that 
syphilitics may marry with safety after they have undergone 



212 



A NURSE'S HANDBOOK OF OBSTETRICS. 



three years of thorough treatment and been free from symptoms 
for a year after the last treatment. 

Paternal transmission of the disease is usually during the first 
and second stages. A patient who has tertiary lesions may have 
healthy children ; but more often pregnaney results in a dead and 
typically maeerated foetus or an infant afiiieted with the disease. 

It is a disease transmitted from man to man and there is no 
intermediate host. The knowledge concerning it is widespread. 
It is a communicable, preventable disease, and stands unequalled 
in its destruction of human life. 

Being, as has been said, the most common cause of all abor- 
tions, it leads as a factor in causing infant mortality. Nowhere 
will pre-natal care secure more definite results. A positive diag- 
nosis and treatment will lessen the damage to the child. Mercury, 
in the form of baths, inunctions, subcutaneous injections and 
internal administration, is usually ordered to control the condi- 
tion during pregnancy. Potassium iodide is often administered 
in conjunction with mercury. Salvarsan treatment early in 
syphilis will prevent the further spread of infection. 

A nurse may use her knowledge wisely and report symptoms 
observed in a patient and so save the life of the infant. 

A new-born infected babe will show a typical snuffle, a gen- 
eral eruption, ulcers on the mucous surfaces, and marasmus. 

Beaumes' or Colles law: " that a child born of a mother who 
is without obvious venereal symptoms, and which, without being 
exposed to any infection, subsequent to its birth, shows this 
disease when a few weeks old, this child will infect the most 
healthy nurse, whether she suckle it or merely handle and dress 
it, and yet this child is never known to infect its own mother, 
even though she suckle it while it has venereal ulcers of the lips 
and tongue." 

The nurse may recognize some of the symptoms and will im- 
mediately take steps to prevent the highly communicable infec- 
tion from spreading. She will report the matter to the doctor 
and use every precaution that will protect the household and 
herself. She will nurse the patient as she would any contagious 
disease. Wear a gown and rubber gloves. As fast as possible 



GONORRHOEA. 213 

destroy all discharges, by burning. Strictly individual articles 
must be used and kept inside the patient's room. Plenty of 
running water and antiseptic solution will be needed. A nurse 
will do well in caring for what is called a venereal disease to 
remember that many are innocent victims and her patient is 
under no circumstances to be told she has such an affliction. Her 
condition and symptoms must not be discussed or mentioned. 

The nurse must hold close to her school version of the Hip- 
pocratic oath and hold inviolate her knowledge of the patient's 
life. If she fails in this trust imposed upon her, she has failed in 
her whole life work ; and she should never forget that a word, or 
even a look, may inaugurate a domestic cataclysm. 

Gonorrhoea is said to be even more prevalent than syphilis. 
The point of infection first shows the reaction to be gonococcus. 
It invades the genital tract, causes inflammation, produces nu- 
merous complications in male and female, and has a most serious 
consequence, sterility. It sometimes invades the blood and a 
general septicaemia and pyaemia result. It may produce an 
arthritis and acute endocarditis, and what chiefly concerns the 
obstetrical nurse is the possible infection of the baby's eyes 
either at birth or later through the lack of care by the nurse. 

The patient usually suffers intensely ; and the nurse, always 
remembering the case to be of an infectious nature, will give all 
nursing care, such as douches, treatment, tampons, etc., with 
scrupulous regard for technic. The doctor concentrates or- 
dinarily upon controlling the acute manifestations of the disease 
before confinement, and should a puerperal peritonitis follow, 
the measures for relief of the pelvic pain are usually a peritonitis 
bed and ice-caps to pelvis, with liquid diet. These cases require 
the best of intelligent care and absolutely perfect technic to 
avoid infection of the infant's eyes, navel or genitalia. The 
doctor may use injections of serum to control the infection. 

All of the eruptive fevers, syphilis, tuberculosis, malaria, 
and lead and sewer-gas poisoning may directly affect the foetus 
in utero ; and although the last two conditions do not cause any 
very serious disturbances if the child lives, they are very apt to 
cause abortion at an early period. 



XVII 

Operative Delivery 

Operative delivery may be either instrumental or non- 
instrumental. 

Instrumental delivery may be further divided into three 
classes, — cutting operations, non-cutting operations, and muti- 
lation of the foetus. 

The non-instrumental form of delivery consists in turning 
the foetus with the hands from an undesirable into a desirable 
position in the uterus. This operation is termed version, and 
may be performed in any one of three ways, — by external ma- 
nipulation through the abdominal wall alone, called " external 




Fig. 75.— Internal version. (Garrigues.) Entire hand in the uterus grasping a foot. 
As the foot is drawn down the protruding arm will be drawn up into the womb, and the 
child will be delivered by the breech. 



version ;" by internal manipulation through the vagina alone, 
called "internal version" (Fig. 75); and by a combination 
of these two methods, in which one hand is placed on the abdo- 
men of the mother and the other in the vagina with the finger- 
214 



VERSION. 215 

tips in the uterus, called " combined version" or the " Brax- 
ton-Hicks Method" (Fig. 76). 




Pig. 76. — Combined or bipolar version. (Garrigues.) The finger in the vagina is assisted 
by the other hand on the abdominal wall. 

External version can only be performed before labor has 
begun, or immediately after and before the membranes have 
ruptured. It is often employed to convert a breech or trans- 
verse presentation into that of the vertex when the abnormality 
is recognized at a sufficiently early date to admit of the neces- 
sary manipulation. 

The combined, bipolar, or Braxton-Hicks method has a 
not much wider field of usefulness than the external method, 
and must also be done before or very early in labor. The finger- 
tips in the uterus push the undesired presenting part to one side, 
while the other hand of the operator presses through the abdom- 
inal wall and forces the desired fetal pole into the pelvis. The 
operation requires considerable skill and great patience and 
perseverance, and really amounts to turning the fcetus around 
in the uterus and passing it along in a gradual, jerky way over 
the finger-tips until it is in a proper position. 

Neither external nor combined version call for the admin- 



2l6 



A NURSE'S HANDBOOK OF OBSTETRICS. 



istration of an anaesthetic unless the patient is in an extremely 
nervous condition or her abdominal wall is rigid and unyielding. 
The operation is not at all painful, but is often unsuccessful, 
either because it proves to be entirely impossible, or, as is more 
often the case, because the foetus returns to its original position 
within a few hours. 




Fig. 77. — " External version. 



The patient is to lie on her back, with her knees drawn up 
enough to relax the abdomen, and as soon as the fetal position 
has been corrected a firm binder should be applied with long 
pads on each side of the belly to prevent any change of position. 

In these two forms of version the head of the foetus is almost 
invariably the part that is brought into the pelvis, and frequently, 
as soon as this is accomplished, the physician will rupture the 



FORCEPS OPERATIONS. 



217 



membrane artificially and allow labor to proceed at once. 

When internal version is performed the entire hand is 
introduced into the uterus, and instead of the head, as in the 
external and combined methods, a foot is grasped and brought 
down into the vagina, or even out of the vulva, converting the 
case into one of breech delivery (see Fig. 75). 

The patient is to be placed on her back in the lithotomy 
position, with her legs elevated and held by assistants or sup- 
ported in a leg-holder. Anaesthesia is always necessary, and 
should be carried to the degree of complete unconsciousness. 
The os uteri must be dilated sufficiently to admit the closed fist 
of the operator before the operation is begun, or rupture of the 
uterus may result ; the membranes must, of course, be ruptured, 
in order that the surgeon may grasp a foot, and the bladder must 
always be empty. 

While external and combined version carry no danger what- 
ever to either mother or child except, in the latter variety, 
through possible infection of the uterus by a surgically unclean 
operator, internal version is extremely dangerous to the infant, 
and to the mother is one of the most perilous operations of sur- 
gery, not excepting those which necessitate opening the abdomi- 
nal cavity. 

Of the non-cutting instrumental operations, the most com- 
mon is FORCEPS DELIVERY. 

Forceps are merely metal substitutes for hands, which can 
grasp the sides of the fetal head, or rarely the breech, and draw 
it down and out of the pelvis (Fig. 78). 

Forceps operations are divided into three classes, — high, 
medium, and low. The high operation is done when the head 
is at or above the pelvic brim. It is extremely dangerous to 
the mother on account of the possibility of rupture of the uterus, 
and may be even more serious than version. The medium 
operation is done when the head has passed through the brim 
but lies in the vagina and does not yet distend the perineum. 
The low operation is done when the head lies well down on 
the perineum and pushes forward the vulva so that it is, in 
many cases, in plain sight. 



2i8 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 78.-Forceps applied to head of brim. (Gafrigues.) 




Fig. 7<j. — Walcher posture. This position tilts the pelvis forward and increases the true 
conjugate diameter nearly half an inch. 



FORCEPS OPERATIONS. 



219 




Fig. 80. — Patient in sling sheet. Ready for vaginal operation. 

In all forms of forceps deliveries the os uteri must be fully- 
dilated, the membranes ruptured, and the bladder empty before 
the instruments are applied. 



220 A NURSE'S HANDBOOK OF OBSTETRICS. 

The patient lies in the lithotomy position on a bed or table, 
with her buttocks drawn well over the edge, and, except in the 
case of a low operation, complete anaesthesia is required. If 
an anaesthetic is not used the patient may struggle and injure 
herself severely with the instruments. 

In certain rare cases where difficulty is encountered in making 
the head enter or " engage in " the pelvic brim, the physician 
will wish the patient placed in the Watcher posture (Fig. 79). 
This consists in lowering the legs until they hang freely over 
the edge of the table, while the buttocks are raised by means 





J 



Fig. 81. — Sterile pillow cases for covering the limbs. 

of a thick pillow or a folded blanket. This tilts the pelvis for- 
ward, so that there is an increase of nearly half an inch (one 
centimetre) in the true conjugate diameter of the inlet; but to 
be effective, the position of the woman must be such that she 
is just at the point of slipping off the table, — an accident to be 
avoided by support from assistants at her shoulders and hips. 
The most common types of forceps are the "Elliott" (Fig. 
83) and " Simpson " (Fig. 85) patterns, with fenestrated blades, 
the " Tucker-McLane " instrument (Fig. 85), with solid blades, 



FORCEPS OPERATIONS. 



221 




Fig. 82. — Kitchen table utilized for operating table. Kelly pad of white rubber sheeting. 

Improvised. 

and the "axis-traction " forceps (Fig. 86), which is only used 
for performing the high operation. With the axis-traction 
instrument the handles are used merely for applying the blades, 



222 



A NURSE'S HANDBOOK OF OBSTETRICS. 



and all the traction force is exerted on a handle-bar, which is 
attached, after the instrument is in place, to rods fastened to 
lower part of blades. It is a very powerful instrument, and a dan- 
gerous one in the hands of an operator unaccustomed to its use. 

Forceps, like other instruments, should be boiled before use, 
and the nurse should have ready sterile vaseline, lysol solution 
i per cent., always warmed, or other suitable lubricant for 
anointing them and the hands of the operator. 

The indications for the performance of version or the use 
of forceps do not especially concern the nurse, but in general 
it may be said that external and combined version are performed 
as prophylactic measures to correct a malposition before or 
early in labor; internal version is done when, for any reason, 




Fig. 83. — Elliott's forceps. 

speedy delivery is necessary, as in cases of eclampsia or of 
hemorrhage ; low and medium forceps are chiefly indicated in 
cases of uterine inertia, when the patient is exhausted after pro- 
longed expulsive efforts ; and high forceps are used usually on 
account of pelvic contraction or overgrowth of the foetus. These 
statements are, of course, made in a very general way, and must 
not be regarded in any other light, for the subject is a very 
complex one and cannot be treated briefly. 

Often, before performing version or using forceps, the sur- 
geon finds it necessary to dilate the cervix artificially. He may 
do this with his fingers or hands, or he may use rubber bags 
distended with water. These bags are of two kinds, — the 
"Barnes" bag (Fig. 87), which is fiddle-shaped, and the 
" Champetier de Ribes " bag (Fig. 88), which is conical. Both 
varieties come in sets of different sizes, and the largest one that 



FORCEPS. 



223 




"Pig. 84. — Simpson's forceps. 




Fig. 85. — Tucker-McLane forceps. 




Fig. 86. — Tarnier axis-traction forceps. 



224 



A NURSE'S HANDBOOK OF OBSTETRICS. 



can be inserted is passed into the cervix and slowly distended 
with water pumped in through a Davidson syringe (Fig. 89). 
The water should be warm (no° F.), and must invariably be 
sterilized by boiling, so that if a bag bursts the accident will 
cause no danger of infection. The bags themselves should, 
of course, be boiled to sterilize them inside and out, and before 
this is done the nurse should test each bag by pumping it full 
of water to make sure that it does not leak. This can be much 
more aseptically accomplished by the use of a large glass syringe. 
A Davidson syringe cannot be made sterile except by prolonged 





Fig. 87. — Barnes's bags. For rapid dilatation of the cervix. 

soaking in solution of bichloride of mercury 1 : 1000; the valves 
and irregular surfaces are also far from satisfactory. 

The bag, whether of the Barnes or Champetier de Ribes 
pattern, is passed into the cervix by means of a specially con- 
structed instrument or with an ordinary sponge-holder. In 
private practice the nurse will often be called upon to hand the 
bag, grasped in the forceps, to the surgeon for introduction, 
and it should be rolled or folded as compactly as possible and 
secured between the blades of the instrument. 

The most important of the cutting operations on the 
mother is that by which the child is extracted through an in- 



CESAREAN SECTION. 



225 



cision in the abdominal wall and uterus. This operation is called 
" Cesarean section/' the name being supposed by some au- 
thorities to have reference to the alleged fact that Julius Caesar 



Fig. 88. — Champetier de Ribes bag. 




Fig. 89. — Bulb and valve, or " Davidson " syringe. 

was born in this manner, while other maintain that the word is 

derived from the Latin ccpsus, from cocdere, to cut. 

Cesarean section may be performed in one of two ways, 

— the entire uterus and its appendages may be removed, or the 
15 






A NURSE'S HANDBOOK OF OBSTETRICS. 



uterus may merely be incised, the infant and placenta extracted, 
and the wound closed with catgut sutures, after which the 
abdominal incision is closed in the ordinary way. 

Formerly, when the Cesarean operation was one of the most 
dangerous in surgery, it was customary to remove the uterus, 
ovaries, and tubes, if for no other reason than to prevent the 




Fig. 90. — Method of inserting bag. 

possibility of a subsequent pregnancy, but at the present time 
there is so little danger attached to this form of delivery that 
most operators prefer to leave the uterus, unless it is itself the 
seat of disease. Few accoucheurs will attempt this operation in 
a private house, the patient usually being hurried to the protec- 
tion of the nearest hospital operating-room. 

Caesarean section is not to be regarded as an emergency 
operation. That is to say, it should not be performed without 



CESAREAN SECTION. 



227 



due preparation, and never, if it can be avoided, when the pa- 
tient is exhausted after protracted labor and futile attempts at 
delivery by forceps or version. Under such circumstances it 
is very apt to result fatally to the mother either from shock or 
infection or both, while, if it is performed by a competent sur- 
geon either just before or immediately after the natural onset of 




Fig. 91. — Method of inflating bag. 

labor, with the patient in good condition and all necessary con- 
veniences and assistants at hand, it is almost universally success- 
ful. Consequently, it is easy to understand that the best results 
in Caesarean section will follow careful and thorough ante- 
partum examination, by which the surgeon may know in ample 
time that the patient cannot by any possibility be delivered of 
a living child through the natural passages at full term or at 
any period of pregnancy sufficiently advanced to permit of its 



22 8 A NURSE'S HANDBOOK OF OBSTETRICS. 

living. It is hardly necessary to say that the operation subjects 
the child to no danger whatever, and that if it is in good con- 
dition at the time when the abdomen is opened it will be de- 
livered successfully. 

The chief indication for Cesarean section is contraction or 
deformity of the pelvis which is so marked that it is impossible 
for a viable child to pass through it even with the assistance 
of forceps or version, and it may also be rendered necessary 
by the presence of abdominal tumors (Fig. 92), cancer of the 




Fig. 92.— Pelvic tumor preventing delivery. (Garrigues.) Large ovarian cyst, in front of 
head, obstructing the genital canal. 

cervix, overgrowth of the foetus, monstrosity, certain cases of 
twins, and certain malpositions of the foetus which cannot be 
corrected. 

In malignant disease ( cancer ) of the cervix the uterus and 
appendages are usually removed at the time of the operation, 
unless the mother is already in a hopeless condition and the 
section is performed solely in the interest of the child. 

As in any other abdominal operation, the patient lies on her 
back on a firm table, with a Kelly pad under her buttocks (Fig. 
93). All the hair on the abdomen, mons Veneris, vulva, and peri- 
neum is to be carefully shaved off, and the belly, external genitals, 



CESAREAN SECTION. 



229 



and thighs scrubbed and disinfected with the utmost care. The 
vagina is also usually made as sterile as possible, but this is 
generally performed by the surgeon or his assistant, and need 
not be taken up by the nurse, except under definite instructions. 
The case calls for at least two nurses, and four assistants to 
the operator. The head nurse has direct charge of the solutions, 
irrigation, and dressings, and the second nurse makes herself 
generally useful. The operator stands at the right side of the 
patient, facing her head; opposite him is the first assistant, 
facing the patient's feet. Standing on the same side of the 




Fig. 93. — Kelly pad in position under patient, with apron draining into tub or pail. 

patient as the first assistant, and facing him, is the second assist- 
ant, whose duty is usually to grasp the blood-vessels at the 
cervix after the abdomen is opened and control hemorrhage as 
much as possible when the uterus is incised. The third assist- 
ant gives the anaesthetic, and the fourth stands behind the oper- 
ator, out of the way, ready to take charge of the baby the instant 
it is extracted. The head nurse stands between the first and 
second assistants, facing the operator, but at a sufficient distance 
from the patient to be out of the way, and at her side should be 
a table with flasks (Fig. 94) or pitchers of saline solution (six- 
tenths per cent.) at a temperature of 118 F. and plenty of hot 
sterile water, cotton sponges (Fig. 95) in holders (Fig. 96), and 
intestinal pads. The pads, for holding back the intestines as the 



530 



A NURSE'S I1AXOROOK OF OBSTKTR1CS. 



uterus contracts, must be supplied with long tapes and carefully 
counted and recorded before the beginning of the operation. 

The second nurse must keep a close watch on her superior, 
so that she can obey a glance instantly. 

The anaesthetist is to he provided with a small table for his 
hypodermic syringe, which must be tested and seen to be in per- 





Fig. 94. — Sterile salt solution in flasks. Fig. 95.— Sponge made of cotton and gauze. 

feet working order, tongue-forceps, throat-swabs, and stimu- 
lants, and the surgeon's instruments are laid out (usually by 
himself in definite arrangement) on a table close by his side 
where he can reach them easily. Some surgeons prefer a fifth 
assistant to pass instruments, but as this plan increases the dan- 




Fa;. 96. — Sponge holder. 

ger of infection by bringing another (and unnecessary) pair of 
hands into the case, it is gradually being abandoned. 

The essential things for the nurse to have ready in private 
practice are : 

A room, as clean as soap, water and a knowledge of proper 
aseptic conditions can make it. 



CESAREAN SECTION. 231 

Protection for the carpet, unless it is removed altogether, for 
blood and solution readily escape to the floor. 

A firm table for operating, narrow and long. Usually two 
kitchen tables, placed end to end, answer perfectly. These should 




Fig. 97. — Intestinal pad of folded gauze. Usual size about eight by ten inches. The 
tape extends out of the wound during the operation to avoid the possibility of leaving a 
pad behind when the abdomen is closed. 

be covered with a clean blanket, rubber sheeting, and sterile white 
sheet, all pinned securely in place. 

A table for instruments at the right side of the patient, with 
space between it and the operating table for the surgeon to stand. 
This, of course, is to be covered with sterile towels or sheet. 




Fig. 98. — Gauze packing. 

A table for dressings, sterile rubber gloves, packing, solu- 
tions, etc., on the left side of the patient, about four feet away, 
also covered with sterile or bichloride towels. 

A small table at the patient's head for the anaesthetist. 

Two clean slop-jars or pails with covers, one on either side of 



232 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 99 — Saline infusion. 



the operating-table, for receiving soiled towels and sponges and 
as much of the blood and solutions as can be directed into them. 

Two dozen sterile towels. 

Five gallons of sterile salt solution, with enough boiling 
water to raise it instantly to any desired temperature. 

Three dozen large safety-pins. 



CESAREAN SECTION. 



233 



Sterile irrigator completely equipped for giving a hypodermo- 
clysis or infusion. 

Pitchers or flasks for pouring salt solution. These must be 
sterilized and wrapped in sterile or bichloride towels. 

Hot and cold water in large pans, and ice, all in a distant part 
of the room, for resuscitating the baby. 

A warm bed for the baby. 

A warm bed for the mother, with plenty of hot-water bottles, 
and provisions for raising the foot of the bed in case of shock. 
In emergencies the best hot-water bottles are beer bottles with 
patent stoppers, which can be corked rapidly and securely. 

Bichloride tablets ; iodine ; 95 per cent, alcohol. 

Tincture of green soap, eight ounces. 

Four nail-brushes. 

Four wash-bowls of good size for hand cleaning. 

Two or three extra wash-bowls for solutions. 

Hot and cold sterile water for scrubbing the hands. 

A warm room (75 to 8o° F.). 

A good overhead light. 

The surgeon should bring all necessary instruments, pads, 
gauze packing, and dressings, and may be expected to do so 
unless he expressly instructs the nurse to provide them. Ob- 
stetrical nurses rarely have the opportunity to perfect themselves 
in operating technic, owing to the large percentage of normal 
deliveries or minor repair cases, the abnormal deliveries usually 
being sent to a hospital if such a thing is at all possible. For 
this reason she is strongly urged to embrace every possible oppor- 
tunity to witness or assist in obstetrical surgery. In a laparotomy 
or Caesarean section one of her greatest responsibilities during 
the operation is to keep track of the sponges. She should not 
use one single sponge, even before the abdomen is open, that is 
not attached in such a manner as to make its loss practically im- 
possible. The method outlined in the operative chapter is the best 
devised and is given in detail for particular use in Caesarean sec- 
tion, by nurses to whom such cases are only a rare occurrence. 
Surgeons are more and more rejecting the use of small free 
sponges on holders as dangerous, and are using only large sponges 



234 



A NURSE'S HANDBOOK OF OBSTETRICS. 



on tapes attached by some mechanical arrangement which ab- 
solutely prevents their being permanently enveloped by the ab- 
dominal viscera. 

A supplementary operation, the removal of the tubes, may be 
done. The nurse will watch the abdominal dressing and the va- 
ginal discharge for hemorrhage. The baby, if alive, will per- 
haps not be able to nurse as soon as usual ; but aside from this 
the usual routine is observed. 

The different operations are variously styled : Conservative 
Caesarean Section ; Porro-Caesarean Section, which may include 
the removal or amputation of the uterus ; Extraperitoneal Caesar- 
ean Section for unclean infected cases ; Post-mortem Caesarean 
Section (to save a child alive after the mother's death) may 




Fig. ioo. — Galbiati knife. For cutting through the symphysis pubis in symphyseotomy. 

be successful if done quickly; and Vaginal Caesarean Section, 
where a hurried delivery is indicated or the cervix does not dilate. 
Every means must be immediately available to meet any emer- 
gency ; particularly shock, hemorrhage, violent or persistent nau- 
sea, acute pain, hiccough, etc. 

Symphyseotomy is an operation once in high favor among 
certain operators, but now, in view of the almost uniform success 
of properly timed and skilfully performed Caesarean section, 
gradually passing into disuse. It consists in cutting through the 
cartilage lying between the ends of the two pubic bones at the 
symphysis pubis and allowing these bones to separate for a dis- 
tance of about one and one-half inches, so as to make greater 
space for the passage of the head. The chief objection to the 
operation is that after this separation has occurred it is not at all 
certain that enough room will have been gained to permit de- 
livery, and it may, after all, have to be completed with forceps or 



SYMPHYSEOTOMY. 



235 




PlG. ioi. — Nurse's proper operating gown, Fig. 102. — Doctor's proper operating gown, 
cap, mask, and gloves. cap, mask, and gloves. 



2$6 A NURSE'S HANDBOOK OF OBSTETRICS. 

by version. Moreover, in some few cases the bones have failed to 
unite after the operation, and the patient has been unable to walk. 

The woman is placed in the lithotomy position, and the legs 
are not supported in leg-holders, but are held by two assistants 
whose duty is to regulate the amount of separation in the joint. 

After the bladder has been emptied and the urethra drawn 
out of the way by means of a male sound passed into the canal, 
an incision is made directly over the symphysis pubis and a curved 
knife, known as the " Galbiati knife " is hooked under the sym- 
physis and drawn up through the joint until the parts are separ- 
ated. A little gauze is then packed into the wound to prevent ooz- 
ing, and while the assistants holding the legs keep them in such 
a position that the separation will not exceed one and one-half 
inches, the labor is allowed to proceed if it will, or is terminated 
by forceps or version if necessary. 

One nurse is all that is needed, and the surgeon requires three 
assistants, one to give the anaesthetic and two to hold the legs. 
The dressings should be provided by the surgeon, and consist of 
iodoform gauze to pack the wound, cotton, plain gauze, adhesive 
plaster strips, and a special binder or a many-tailed bandage. 

Certain operators join the bones with silver wire, but this is 
seldom done now, as it is found that firm coaptation of the parts 
by pressure, with the adhesive plaster drawn tightly around the 
body, will give equally good results. 

The after-care of these cases is very important and very dif- 
ficult, for under no circumstances can the thighs be separated 
until union is complete in the joint, and, as this occupies a period 
of about six weeks, it is extremely trying to the patient and 
troublesome for the nurse. Dr. Edward A. Ayres, of New York, 
has devised a " symphyseotomy bed," which is a sort of canvas 
hammock swung from a high frame and so arranged that a 
strip can be removed from the bottom and the buttocks uncovered, 
when it is necessary to move the bowels or empty the bladder. In 
other cases the patient lies flat on a hard bed, with long sand bags 
at each side of the hips, and when the catheter is used the legs, 
tightly bound together, are raised straight up in the air until 
the thighs are at right angles to the body and the catheter is in- 



MUTILATING OPERATIONS. 237 

serted from below. While but one nurse is actually needed for 
the operation of symphyseotomy, at least two and often three are 
required to give the patient the proper after -treatment. 

Hebsoteotomy or lateral pubiotgmy has largely super- 
seded this operation. The bone near the joint is severed instead 
of the joint itself. This is done by means of the Gigli wire saw 
familiar in other forms of bone work. The carrier, a large 
needle generally, is passed through a puncture to behind the pubic 
bone and the lip of the vulva. When the bone is severed a ver- 
sion or the application of forceps delivers the child. The severed 
pelvis requires careful and skilful handling. 

Bone surgery and obstetric delivery exact most careful technic 
to prevent infection and the nursing care no less. Infection 
of the wound is especially likely to occur owing to its location. 

Episiotomy is an operation designed to substitute for an un- 
avoidable, ragged, central laceration of the perineum, a clean in- 
cision, made with a knife, at each side of the vaginal floor. The 
only instruments required are a scalpel and suture material, with 
needles and needle-holder for immediate repair after delivery has 
been effected. No assistants or special nurse are needed. The 
operation often causes troublesome hemorrhage, and is seldom 
if ever performed at the present time. 

The mutilating operations on the foetus are termed 
"' embryotomy," and are divided into craniotomy, which con- 
sists in crushing the fetal head ; decapitation, or amputation 
of the head; and evisceration, or removal of the thoracic and 
abdominal contents, piece by piece. When evisceration is per- 
formed it is usually necessary to follow it by craniotomy, for 
any condition which will not permit the passage of the chest or 
abdomen will almost certainly interfere to an even greater de- 
gree with the delivery of the head. 

Embryotomy in any of its forms is a rare operation, and 
one that should seldom be necessary if the patient has been 
under careful supervision throughout the course of her preg- 
nancy. Its indications are, in general, the same as for Csesarean 
section, but it is not justifiable unless the child is dead or 
the mother too much exhausted to withstand the shock of 



238 v NURSE'S HANDBOOK OF OBSTETRICS. 

the abdominal operation. This procedure is, of course, neces- 
sarily fatal to the child, but the dangers to the mother from the 
operation itself arc very few indeed, the great difficulty in such 
cases being- that it is usually delayed until the woman is in a 
critical condition, either from exhaustion or from attempts at 
other methods of instrumental delivery. 

Embryotomy is a most unpleasant operation to witness or 
perform, but it is not, as a rule, painful, and an anaesthetic is 
required only to spare the mother the distressing spectacle of 
the mutilation of her infant. 

In almost every case the child is dead when the operation 
is begun, but it must be remembered that it is sometimes justi- 
fiable, in the case of a living child, to save the mother or to save 
one twin (as in cases of locked heads), when otherwise both 
children and possibly the mother herself would be lost. The 
nurse may be consulted by the family in these extremely rare 
cases as to the propriety of performing the operation on the 
living child, and she must not permit sentimental feelings to 
close her eyes to the fact that the mother is of far more impor- 
tance than the unborn child, and that when it is necessary to 
sacrifice the child in order to save the mother the latter should 
always receive the first consideration. It does not take a great 
deal of moral courage to arrive at this conclusion when it is 
remembered that in these cases delay will usually result in the 
loss of both lives, while prompt operation and the sacrifice of 
one may, and probably will, be the means of saving the other. 

Craniotomy is performed by perforating the fetal skull to 
allow escape of brain tissue and then crushing the head into 
as compact a mass as possible for extraction. The usual instru- 
ments for this purpose are the perforator and cranioclast (Figs. 
103 and 104 ) , but the best and most modern appliance is the basio- 
tribe (Fig. 105), which resembles an obstetrical forceps, and 
combines in one instrument the perforator, crusher, and extractor. 

Decapitation is seldom necessary except in the case of 
locked twins (see Fig. 63 ), when the body of the first infant is 
removed after decapitation, the head pushed out of the way while 
the second child is extracted, and last of all the severed head 



DECAPITATION. 



239 



removed with forceps. The operation may also be necessary in 
impacted shoulder presentations (Fig. 106), where the body is 
firmly wedged in the pelvis and cannot be pushed up above the 
brim. 




Fig. 103. — Nacgele's perforator 




Fig. 104. — Braun's cranioclast 




•Fig. 105. — Tamier's basiotribe. 



The only special instrument used for decapitation is the 
" Braun's hook " (Fig. 107), which may either be blunt or sharp- 
ened to a knife edge at the concavity of its crook. 



240 A NURSE'S HANDBOOK OF OBSTETRICS. 

Either hook is to be passed over the neck of the foetus (Fig. 
108), and when the blunt one is used the neck is merely broken 




Pig. 106. — Impacted shoulder presentation. Delivery in this position is impossible and, 
unless it can be corrected, decapitation will be necessary. 

with a twisting motion and the operation completed with long 
heavy scissors (Fig. 109). If the sharp hook is employed, all 
the tissues of the neck are severed with this instrument alone. 
It is also quite possible to perform the entire operation with 
the scissors, and many surgeons do not use either hook at all. 



Fig. 107. — Braun's key-hook. 

Evisceration is accomplished with the long stout scissors 
shown in Fig. 109. 

After any form of operative delivery the danger of post- 
partum hemorrhage is always to be especially feared, and the 
nurse should have ready an ample supply of hot and cold sterile 
water for douches or infusions, in case they are needed, and a 



EVISCERATION. 



241 




Fig. 108.— Braun's hook applied. (Garngues.j 




FlG. 109.— Long, blunt scissors. For decapitation and 

6 



evisceration. 



242 A NURSE'S HANDBOOK OF OBSTETRICS. 

number of hot-water bottles with which to surround the patient 
in case she goes into shock. 

The induction of premature labor is often indicated in 
cases of slight pelvic deformity, and is usually performed at 
about the end of the eighth month of gestation. In these cases 
there is no need of special haste, and the surgeon merely adopts 
such measures as will excite contractions of the uterus, after 
which the labor proceeds as in any normal case at term. 

There are three methods in ordinary use for starting up labor- 
pains. These are: the introduction of an elastic bougie, about 
the size of a lead-pencil (Fig. no), into the uterus; packing the 



=03 



Fig. i io. —Bougie for the induction of labor. About the size of a lead-pencil (No. 

American scale). 



cervix and vagina with gauze ; and the use of an elastic bag 
of small size, which is passed into the cervix, distended with 
water, and allowed to remain until uterine contractions force 
it out. 

The first, or " Krause," method is the one most commonly 
employed, and is perfectly safe. Its objections are its uncertainty 
and the danger of rupturing the membranes and causing " dry 
labor." The bougie should be about the size of a lead-pencil 
(No. 12, American scale), with a wire stylet to facilitate its intro- 
duction, and it is prepared for use by soaking it for twenty-four 
hours in cold bichloride solution (i to iooo) after it has been 
thoroughly washed with soap and water. 

The patient is usually placed in the lithotomy position at 
the edge of the bed or table, but some physicians prefer Sims's 
position (Fig. in) in these cases. Xo anaesthetic is required, as 
the operation is absolutely painless and of but a moment's dura- 
tion. 

Labor-pains usually begin in from thirty minutes to twelve 
hours after the insertion of the bougie. If there are no develop- 
ments at the end of twenty- four hours, it may be removed by 
the surgeon and inserted in a new place, or a second bougie 



INDUCTION OF PREMATURE LABOR. 243 

may be passed in alongside of the first. In some cases it is neces- 
sary to use three bougies before labor-pains begin. Gauze is 




Fig. in. — Sims's position. The patient lies on her left hip, her chest nearly flat on the 
table, her left arm hanging over the edge and her right leg drawn well up above the left 
knee. 

required to pack the vagina after the introduction of the bougie, 
but the physician usually supplies everything of this sort him- 
self. 

None of the methods named for the induction of labor is 
at all painful, and after the bougie, gauze, or bag has been in- 
serted the patient may be up and on her feet as in the first stage 
of normal labor. 

If the membranes rupture, the nurse should report the fact 
at once to the physician, and he should be notified, as in any 
other case, the moment true labor-pains are established. 

With the exception that these cases are artificially started, 
they do not differ in any respect from ordinary labor, nor do 
they subject either mother or child to any greater danger. 

When haste in delivery is an essential factor, as in eclampsia 
or hemorrhage, the surgeon dilates the cervix under complete 
anaesthesia, either manually or with bags, and delivers by for- 
ceps or version. As version offers the most rapid means of 
delivery at our command, it is usually the method chosen. 



XVIII 

Abortion and Miscarriage 

Abortion, miscarriage, and premature labor are all terms 
which indicate the premature discharge of the foetus from the 
cavity of the uterus. When the embryo is expelled before the 
end of the third month of gestation, the word " abortion" is, 
technically, the correct term to employ ; while from the end of 
the third month up to the earliest date at which the child can, 
by any possibility, live (about six and a half months) the term 
" miscarriage" is used. If the woman is delivered at any time 
after the middle of the sixth month and within about two weeks 
of the proper end of her pregnancy, the birth is described as 
" premature labor." While, as has been said, the expulsion of 
the uterine contents during the first three months of gestation is 
technically termed " abortion," this word is so intimately asso- 
ciated in the public mind with some form of criminal procedure 
that the nurse should never use the word under any circum- 
stances, but group all such accidents occurring before the period 
of viability of the child under the general term " miscarriage." 

The first symptom of either abortion or miscarriage is usually 
pain of an intermittent character, followed soon by bleeding due 
to the separation of the placenta from its uterine attachment. 
In some cases the bleeding appears first, and the pain, which 
is of a " bearing down" type resembling that of labor, comes 
later. 

Premature emptying of the uterus at any time may be caused 
by fright, grief, or other form of severe nervous shock ; it may 
result from disease of the mother or of the foetus, or from 
external injury, such as a fall, or a blow or kick over the 
abdomen. In the latter class of cases the element of fright 
must also be considered. Whenever the mother is suffering 
from an acute febrile disease she will surely miscarry if the 
temperature reaches 105 ° F., and she may do so at a much lower 
244 



ABORTION AND MISCARRIAGE. 



245 



degree. Hence in such cases the nurse must be always on the 
lookout and fully prepared for this accident. 

When abortion or miscarriage threatens the patient she is to 
be put in bed on her back and kept perfectly still until the 
physician arrives. The nurse should elevate the foot of the bed, 
and place pillows under the patient's buttocks so as to increase 
the elevation of the pelvis. ,If the symptoms are severe, one-sixth 
grain of morphine may be given hypodermically to relieve the pain 
and allay the nervousness of the patient. In many cases this 
treatment will be all that is necessary, and the pain will cease, 
the bleeding stop, and the case go on to full term without 
further interruption. In other cases the symptoms will increase, 
and eventually the fcetus and its envelopes will be expelled from 
the uterus, either wholly or in part. The bleeding in these 
cases is seldom if ever enough to cause any serious alarm before 
the physician arrives, but it is of the utmost importance for the 
nurse to save for his inspection every particle of blood or other 
matter that comes away from the uterus. In many cases the 
embryo is so small that it is easily lost in a blood-clot, and 
unless the physician is afforded an opportunity of examining 
the discharges himself he cannot know exactly how much, if 
any, of the ovum has been expelled. Lacking this positive 
knowledge of the actual condition of affairs, the surgeon is 
obliged, in the interest of his patient, to proceed as if part, at 
least, of the ovum remained in the uterus, and a little care and 
forethought on the part of the nurse might have been the means 
of saving the patient the discomfort, not to say the danger, of 
a curettage under ether. 

Abortion and miscarriage are by no means the trivial matters 
that they are so commonly supposed to be by women in general. 
The process is distinctly an abnormal and unnatural one, and 
as the uterus is not prepared to cast off the placenta as it would 
at the normal end of pregnancy, some part of it is almost certain 
to be retained in the cavity of the uterus. These retained frag- 
ments of placental tissue cause chronic inflammation of the 
membrane lining the uterus, even if they do not decompose and 
result in " blood poisoning," with the possible death of the 



j 4 (, \ NURSE'S HANDBOOK OF OBSTETRICS. 

patient. In any event the outcome is bound to be serious unless 
the case is most carefully and intelligently treated, and even in 
those eases in which the entire ovisac has apparently come away 
a thorough curettage under general anaesthesia is usually indicated 
as the safest procedure to follow. The nurse should use all her 
influence to impress upon patients the serious nature of abortion 
and miscarriage when proper treatment is neglected or refused ; 
and it is safe to say that the dangers to the woman are consider- 
ably greater than are those which follow in the train of a normal 
labor at term. 

An abortion is spoken of as complete when the entire uterine 
contents are expelled. It is called an incomplete abortion when 
some part of the membranes or placenta is retained. Here there 
is often much hemorrhage and discharge. A threatened abortion 
indicates a possible loss of contents of uterus but with proper 
care pregnancy may not be terminated. 

If curettage is to be performed after abortion or miscar- 
riage, the preparations for the operation are the same as when 
it is indicated in any other condition. If there is sufficient time 
a soapsuds enema with one drachm of turpentine should be given 
to thoroughly empty the lower bowel. No solid food should be 
allowed within six hours of the operation, on account of the 
ether. 

The woman is to be etherized and prepared for operation in 
precisely the same manner as for forceps delivery except that, 
if possible, she should lie on a firm table instead of on the bed. 
She is to be placed in the lithotomy position, and the legs are 
to be supported in some form of leg-holder (Figs. 112 and 113), 
or with the metal leg supporters screwed to the sides of the 
table if the physician has them. A strong, narrow kitchen 
table is the best for use in private practice, and it is to be 
covered with a folded blanket, rubber sheeting, and a clean 
white sheet, all pinned securely under the corners. As the 
patient will be removed to her bed as soon as the operation 
is concluded, she may be anaesthetized in bed, and need not 
know that a table is to be used. Many women, who will submit 
to almost any surgical procedure so long as they are not re- 



CURETTAGE. 



247 



moved from their beds, are stricken with terror at the mere sug- 
gestion of performing the same operation on a table, and it is 
best to keep all preparations out of their sight as far as possible. 
The instruments used for curettage are — 





Fig. 112. — Author's leg-holder. 



Pig. 113. — Robb's leg-holder. 



Sims's speculum (Fig. j 14), or a vaginal retractor (Fig. 115). 

Bullet forceps (Fig. 116). 

Goodell uterine dilator (Fig. 117) occasionally. 

Uterine sound (Fig. 118). 

Placenta forceps (Fig. 119). 

Curette (Fig. 120) according to the case or to the individual 
preference of the operator. 

Sponge-holders (Fig. 121) at least four. 

Uterine applicators, four or five, wrapped with cotton. 

Double current eatheter( Fig. 122). 

A Kelly pad is to be placed under the patient's "buttocks, to 
drain into a pail at the foot of the table, and there should be a 
small table at the head for the hypodermic syringe and other 
articles used by the anaesthetist. A chair should face the buttocks 
for the operator, and at his right-hand side should be a low table 
within easy reach for his instruments. In private practice a 
dress-maker's " cutting table," to be found in nearly every 



248 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. i i 4 . -Sims's speculum. 




Fig 



"5—Schroeder's vaginal retractor. 




Fig. ii7.— Modified Goodell-Elli 



nger dilator. 



INSTRUMENTS. 



249 




Fig. 118.— Uterine sound. 




Fig. 119. — Placenta-forceps with heart-shaped jaws. 



Sims's sharp curette. 



Simon's sharp curette. 




Recamier's dull curette. 



Thomas's large dull wire curette. 
Fig. 120.— Curettes. 




Fig. 121.— Sponge-holder. 



250 A NURSE'S HANDBOOK OF OBSTETRICS. 

house, is best for this purpose. The carpet at the foot of the 
operating-table is to be protected with many layers of old news- 
papers, over which a sheet should be securely tacked. 

A suitable place should be provided for hanging the irrigat- 
ing can, and if the operation is done at night this can usually be 
attached to the chandelier, which will be directly above the pa- 
tient's buttocks. Abundance of sterile water must be available, 
as a douche may be given. This may be of lysol, i per cent., or 
bichloride of mercury i : 3000, or alcohol one ounce, with tinc- 
ture of iodine two drachms to one quart of sterile water. Some 
surgeons use a gauze sponge instead of the curette and swab the 
uterus with tincture of iodine instead of using the douche. 




Fig. 122. — Two-way catheter. (Kelly.) 

If daylight is to be used, the windows must be protected so 
that outsiders cannot see into the room, and yet the supply of 
light must be curtailed as little as possible. If there are lace 
curtains in the window they may be pinned securely together, 
or the windows may be covered with newspapers, white wrap- 
ping paper, or cheese-cloth. Another method is to cover the 
glass with whiting mixed with water to the consistency of a 
thick paste, as it would be used for cleaning silver. There is 
no danger that this covering will fall off, and it scarcely inter- 
feres at all with the passage of light. The operating-table is to 
be placed in such a position that the light will fall over the 
left shoulder of the surgeon. In the daytime the back of the 
operator's chair should be towards the window, and at night the 



CURETTAGE. 251 

patient's buttocks should lie directly under the middle of the 
chandelier. A good nurse will never undertake to prepare for 
a delivery unless she has systematically planned all details, with 
relation to the outline and size of the room, the available light, 
the position of the bed and furniture, the proximity to fire and 
water, and the possible assistants. 

The best way is to put the plan on paper. This clarifies ideas 
and at once shows mistakes before they occur. 

The nurse should have ready one dozen clean towels wrapped 
in parcels, sterilized or baked in the oven, plenty of boiled water, 
both hot and cold, and a long stout sheet, to be used as a leg- 
holder in case the physician does not bring one with him. The 
doctor will carefully scrub his hands according to his preferred 
technic, put on his cap and gown, and sterile rubber gloves. 

The patient should be attired in night-gown and stockings 
only, or a pair of obstetrical stockings or a pair of pajamas may 
be used. The external genitals must be carefully cleansed, and if 
the pudendal hair is at all long or thick, it should be clipped closely 
with scissors, unless the physician wishes the parts shaved. 

After the patient has been etherized, placed in proper posi- 
tion on the table, and covered with sterile or bichloride towels, 
the operator will seat himself in the chair directly facing the 
vulva, insert the Sims speculum or the vaginal retractor to 
depress the perineum, and grasp the anterior lip of the cervix 
with the bullet-forceps to draw it forward. The nurse should 
have everything so arranged that it will not be necessary for 
her to leave the patient's side, and is now to assist the operator 
by standing or sitting at his left hand and holding the retractor 
and bullet-forceps while the operation is in progress. The pa- 
tient's bed is to be made up with rubber sheet, white sheet, and 
draw-sheet, and the pillow should be removed and a large towel 
laid in its place for use as she comes out of ether. 

Hot-water bottles (improvised most readily from beer-bottles 
with patent stoppers) should be at hand at the end of the 
operation, and if the case is at all a serious one the patient 
should be laid between blankets instead of sheets until she 
comes out of ether and reacts from the shock. The doctor may 



252 A NURSE'S HANDBOOK OF OBSTETRICS. 

not curette, but treat the condition by packing the uterus and 
vagina with gauze. Upon removing the packing the placental 
tags or membranes will be attached to the gauze. As a rule no 
anaesthetic is required. 

The after-treatment of abortion and miscarriage, whether or 
not curettage has been performed, consists in the practice of the 
most scrupulous cleanliness and in the frequent removal of all 
discharges from the folds and creases of the external genital 
organs. Douches should never be given except by the express 
order of the physician, and the patient is to remain in bed on a 
light but nourishing diet for at least ten days. 

Premature labor does not differ in its management to any 
marked degree from normal labor. There is, however, more 
of a tendency towards retained membranes or placenta, and the 
shock to the mother in her disappointment over the possible, if 
not actual, loss of her child, often has a serious and very depress- 
ing effect on her nervous system and so upon her convalescence. 
The care of the premature child is discussed in another chapter. 

An abortion is a legitimate abortion when a reputable physi- 
cian, in consultation with a colleague, decides it is necessary to 
save the life of the mother. This may be the case if the mother 
is suffering from a serious constitutional disease of the lungs, 
heart, or kidneys, for example. 

The physician will arrange in every instance possible that 
the operation be done in a reputable hospital. 

If the operation is not necessary, it is called a criminal abor- 
tion, as opposed to a legitimate or legal abortion, and is a penal 
offense. A nurse incurs a grave responsibility if she is guilty 
of expressing her individual opinion upon any case. She has 
enough responsibility in meeting the preparations for the opera- 
tion, if it is to be done in a private house. 



XIX 

Accidents and Emergencies 

The accidents and emergencies of obstetrics may affect either 
the mother or the child, and may occur during the pregnancy, 
the labor, or the puerperium. 

In pregnancy the conditions that may affect the mother and 
call for prompt action on the part of the nurse are eclampsia, 
syncope, hemorrhage, and miscarriage. 

Eclampsia is a most serious complication occurring during 
the last three months of gestation, and is characterized by gen- 
eral oedema, convulsions, and coma. It must be differentiated 
from epilepsy and hysteria, and its management by the nurse is 
fully discussed in Chapter XVI. 

Syncope is usually an unimportant matter, unless it is due 
to toxaemia, and is often associated with anaemia or hysteria. 
The patient should be placed on her back, with no pillow under 
her head ; her clothing loosened, especially at the waist, until 
all constriction is removed ; ammonia applied to her nose ; and, 
as soon as she has recovered sufficiently to be able to swallow, 
whiskey or some other stimulant (such as one drachm of aromatic 
spirit of ammonia) may be administered by the mouth. Patients 
who are subject to attacks of fainting during pregnancy should 
avoid hot, crowded rooms and every form of excitement, and 
be under the direct supervision of a physician at all times. 

Hemorrhage during pregnancy, if occurring only in the first 
three months and of the menstrual type, is not necessarily of any 
consequence, but it should be reported to the physician in view 
of the possibility that it may be one of the early symptoms of 
ectopic gestation. 

Hemorrhage occurring late in pregnancy may be due to pla- 
centa praevia, to the accidental detachment of a normally situated 
placenta, or to the rupture of an ectopic gestation sac. Bleed- 
ing due to placenta praevia is termed " unavoidable " hemorrhage, 
because, from the very nature of the case, it is bound to occur, 

253 



254 A NURSE'S HANDBOOK OF OBSTETRICS. 

sooner or later; while that caused by the accidental separation 
of a normally situated placenta is called " accidental" hemor- 
rhage, since it need not necessarily have occurred except for 
the accident that caused the detachment of the placenta from the 
uterine wall. 

Unavoidable hemorrhage (that due to placenta praevia) is 
always external, and the first symptom of this complication is 
the sudden gush of bright-red blood unaccompanied by pain and 
dependent upon no discoverable exciting cause. The mere posi- 
tion of the placenta at or near the internal os uteri is sure to 
cause bleeding either at or before the beginning of labor. 




Fig. 123. — Concealed hemorrhage. The blood has collected between the placenta and the 
uterine wall, and the patient may bleed to death inside her own body. 

Accidental hemorrhage may be either external or concealed, 
and is accompanied by severe tearing pain at the site of the 
placental separation. In the concealed type the uterus merely 
bleeds into itself (Fig. 123), and the condition can only be recog- 
nized by the severe pain in the uterus and the general symp- 



HEMORRHAGE. 255 

toms of hemorrhage, — namely, collapse, extreme pallor, feeble, 
rapid pulse, disturbances of sight and hearing, excessive thirst, 
and " air hunger." 

Hemorrhage due to the rupture of the sac in ectopic gesta- 
tion is always concealed, the blood escaping into the abdominal 
cavity and the patient suffering from pain of an excruciating 
character on the affected side, accompanied by collapse and the 
general symptoms of hemorrhage mentioned in the preceding 
paragraph. The gestation sac in ectopic pregnancy usually rup- 
tures not later than the fourth month, a period too early for pla- 
cental separation to occur, and this fact is an important factor 
in the differential diagnosis between the two conditions. 

All that the nurse can do in any case of severe hemorrhage 
during pregnancy is to send at once for the nearest physician ; 
put the patient in bed, flat on her back, with as little delay or 
excitement as possible; give a hypodermic injection of mor- 
phine (one-sixth grain), repeating it in fifteen minutes if the 
pain is severe and the hemorrhage not due to placenta praevia; 
make immediate preparations for an operative delivery, or, if 
the case is one of ectopic gestation, for an abdominal section; 
and provide sterile normal salt solution (six-tenths per cent.) 
in ample quantity for infusion. 

It is needless to say that everything must be done in as quiet 
and methodical a manner as possible, and that no knowledge 
of the serious nature of the case must be permitted to reach the 
patient. 

Preparations for operation must be made in an adjoining 
room, and all members of the family who, by their manner, 
would have a tendency to frighten the patient and arouse her 
suspicions must be excluded from her presence on some pretext 
or other. 

Miscarriage may occur at any time during pregnancy, 
either as a result of a blow, fall, or other injury, or from an 
unknown cause. Any of the acute febrile diseases may cause 
miscarriage, and this accident is certain to occur if the patient's 
temperature rises to 105 ° F. Any pregnant woman suffering 
from a febrile disease may be expected to miscarry if the tern- 



256 A NURSE'S HANDBOOK OF OBSTETRICS. 

perature rises to the point mentioned, and whenever the nurse 
sees that the fever is steadily increasing she should make such 
preparations as will be necessary when the miscarriage occurs. 

Miscarriage is seldom if ever accompanied by any immediate 
danger to the patient, although its remote effects may be very 
serious, but the patient is often greatly alarmed at the accident, 
and the nurse must do all in her power to allay her fears and 
make her comfortable in mind as well as in body. 

The first symptoms of miscarriage is pain which greatly re- 
sembles that of labor and is often equally severe. This is soon 
followed by the escape of bloody discharge from the vagina, 
and the diagnosis is positive. 

The woman should at once be put to bed (the head of which 
must be lowered and the foot elevated) . She is then given a hypo- 
dermic injection of morphine (one-sixth grain), and in some 
cases this will be enough to check the contractions of the uterus 
and the case may go on to full term in spite of the threatened 
interruption. The physician should, of course, be summoned at 
the first appearance of symptoms, and if the miscarriage occurs 
in spite of every effort to prevent it, he will usually wish to 
perform a thorough curettage at once. The preparations for 
this operation are described in Chapter XVIII. 

Death of the foztus during pregnancy is usually followed 
by miscarriage, and it is only under these circumstances that it 
can be regarded in the sense of an emergency. 

Occasionally the dead infant is retained in the uterus for a 
considerable period, and when this occurs the diagnosis of the 
condition is often extremely difficult. The symptoms that point 
to the death of the foetus are cessation of fetal heart sounds and 
active movements, general malaise of the mother, the occasional 
appearance of a foul-looking, though not necessarily offensive, 
discharge from the vagina, dull pain in the back and limbs, and 
shrinking and general flabbiness of the breasts and abdomen. 

The physician should be notified if these suggestive symp- 
toms develop, and if he finds, on examination, that the child is 
actually dead, he will usually proceed to empty the uterus at once. 

During labor the mother may suffer from eclampsia, hemor- 



RUPTURE OF THE UTERUS. 



257 



rhage either from placenta prsevia or placental separation, rup- 
ture of the uterus, inversion of the uterus, and sudden death 
from heart failure or other cause due to intercurrent constitu- 
tional disease. 

Eclampsia and hemorrhage have already been sufficiently 
discussed, and as the physician will usually be in attendance at 
this time, the nurse will be relieved of all responsibility. 



P?^ 


■ 4fc 1 


WjMW' .Js 





Fig. 124. — Rupture of the uterus. The specimen is opened opposite the laceration in 
hs wall (A), and the points (B B) indicate the ends of the severed cervical ring. The 
roughened area of placental attachment is plainly seen at the upper part of the uterine cavity. 



Rupture of the uterus (Fig. 124) often resembles greatly 
the concealed hemorrhage of placental separation, the general 
symptoms of shock and collapse being common to both condi- 
tions, but the essential difference is that placental detachment 
occurs before or early in labor, while rupture of the uterus can 
only happen after the woman has been in severe labor for a con- 
siderable time. If the foetus escapes through the tear into the 
17 



2 5 S 



A NURSE'S HANDBOOK OF OBSTETRICS. 



abdominal cavity, Caesarean section will be necessary for its 
removal, while if it can be delivered through the natural pas- 
sages by forceps or version, the surgeon may either open the 
abdomen and sew up the rent, or pack the uterine cavity through 
the vagina with gauze and leave the healing of the wound to 
nature. As the treatment by packing gives, in the general run 
of cases, as satisfactory results as the more radical abdominal 
operation, it is the one most commonly employed. 




Fig. 125. — Complete inversion of the uterus. (Boivin and Duges.) b, right labium 
majus; c, right labium minus; d, clitoris; e, meatus; f, anterior vaginal wall ; g, external 
os uteri ; h, internal surface of inverted uterus. 



Inversion of the uterus is one of the rarest accidents of 
labor, but it may occur in any degree, from a mere sinking 
down of the fundus to an actual turning inside out of the entire 
organ (Fig. 125). It may follow operative delivery, or it may 
be due to shortness of the umbilical cord, either actual, or rela- 



PROLAPSK OF Till- CORD. 



259 



tive by being- wrapped about the infant's body, which drags 
down the placenta and with it the adherent uterine wall. 

After the child is born, inversion may be caused by pulling 
on the umbilical cord to extract the placenta, or, if the uterus 
is empty and relaxed, by improper pressure on the fundus or 
violent straining or coughing by the mother. These last-men- 
tioned cases might better be classed as accidents of the puer- 
perium, but the complication is of such extreme rarity at any 
time that it need only be mentioned in this place. 

The symptoms are severe pain at the point of inversion, hem- 
orrhage which is more severe as the inversion is greater, faintness 
or actual syncope, collapse, and pain in the rectum and bladder. 

The treatment consists in replacing the inverted portion of 
the womb, and is easier the more promptly it is performed. It 
cannot be attempted by the nurse. 

Heart failure and other conditions of a like nature which 
greatly endanger the patient can, in the absence of the physician, 
only be treated by the prompt and energetic administration of 
stimulants, such as whiskey, strychnine, nitroglycerin, and cam- 
phor in olive oil, by the hypodermic needle and oxygen. 

The child may be endangered during labor by malposition, 
prolapse of the umbilical cord, and asphyxia from protracted or 
instrumental delivery. The only malpositions which the nurse 
can be expected to recognize are those accompanied by pro- 
lapse of an arm or leg, but if she finds an extremity protruding 
from the vagina she will, of course, know at once that the case 
is a serious one and send immediately for the physician. 

It is impossible to lay too much emphasis upon the danger, 
to both mother and child, of pulling or tugging upon an ex- 
truded hand or foot. This may be permitted only to a skilful 
physician and then only after all preparations have been made 
for concluding the delivery without delay. The situation may 
be compared roughly to the disentangling of a skein of wool. 
Injudicious traction may, and usually does, only serve to tighten 
the knots and snarls and make a bad matter very much worse. 
The care of the protruding part to prevent infection is also an 
important and serious matter. 



2<5o A NURSE'S HANDBOOK OF OBSTETRICS. 

The properly trained nurse will, after summoning the 
physician at once, devote her attention in such an emergency 
to reassuring the patient as much as possible and preparing 
quickly and unobtrusively for a probable operative delivery 
under complete anaesthesia. 

These preparations are best made in an adjoining room, 
if such an arrangement is available, and should be completed 
as unconcernedly and expeditiously as possible in order that 
everything may be in readiness upon the arrival of the physician. 

The exposed arm or leg of the fetus should be protected 
with warm, sterile towels which are to be renewed as often as 
necessary; but otherwise it must be left severely alone. If a 
second nurse is on duty, or if the mother or a sister or other 
woman who is sufficiently sensible and self-controlled to be 
relied upon, is present, she may be directed to sit by the pa- 
tient's side and make firm but gentle support (not pressure) 
on the abdomen over the fundus uteri. This duty, however, 
should never be entrusted to an excitable person whose nervous- 
ness or anxiety might serve to alarm the patient. In such a 
case it is far better to let her lie quietly and alone, encouraging 
her with tactful words from time to time and, although in- 
specting the prolapsed part and changing the towels at frequent 
intervals, affecting such an apparent unconcern that she will 
not imagine she has anything to dread. 

As soon as the preparations for delivery are completed 
the nurse should seat herself by the patient and take further 
charge of the case herself until the physician arrives. Should 
delivery take place before he comes there is no occasion what- 
ever for alarm and the management of the case is described 
under the heading " Precipitate Labor." 

If the cord prolapses and descends in front of the present- 
ing part (Fig. 126a), the accident is usually due to premature 
rupture of the membranes when the head or breech is not 
sufficiently down in the pelvis to prevent the cord from being 
washed past it in the sudden gush of amniotic fluid. Unless 
the cord is carried down to the vulvar orifice, the nurse is not 
likely to know that this complication has arisen, for in private 
practice she is not expected to make any vaginal examinations 




Fig. 126a. — Prolapse of the umbilical cord. (Bumm.) As the head comes down the com. 
pression of the cord between the fetal skull and the pelvic brim will shut off its circulation 
completely. 




Fig. 126b.— Knee-chest position. (Potter). The back must be straight or slightly concave 
and the thighs perpendicular. 



TRENDELENBURG POSITION. 261 

whatever, except for special reasons of the utmost urgency. If, 
however, she knows that the cord has prolapsed, she should send 
at once for the physician and then put the patient in the " knee- 
chest " position, or in the Trendelenburg position, easily arranged 
by slipping a straight chair-back covered with a flat pillow under 
the buttocks and shoulders of the patient. The knees should fall 
downward over the chair round toward the bed. This will favor 
its return into the cavity of the uterus. If the pulsations in the 
cord cease or even grow feeble or irregular, there can be no ob- 
jection to an attempt at its reposition with the hand. 

With the patient in one or the other of the positions named, 
the nurse should pass her entire hand, thoroughly scrubbed and 
disinfected, and wearing sterile rubber gloves, well lubricated 
with sterile vaseline or lubrichondrin, into the vagina and try, 
with the utmost gentleness, to push the cord up into the uterus 
past the presenting part until it falls entirely out of reach. This 
is often a very difficult thing to do, on account of the tendency 
of the cord to prolapse as soon and as often as it is replaced, 
but if the nurse has been thorough in the disinfection of her 
hands and in her observance of all the rules of asepsis, no harm 
can result from the attempt, and it may be the means of saving 
the infant's life. The patient's hips must be kept raised above 
the level of her shoulders, or the cord will be almost certain to 
come down again into the vagina, and this can best be accom- 
plished by placing a thick pillow or cushion under her buttocks, 
for it will be found quite impossible for her to remain in either 
the " knee-chest " or the Trendelenburg position for any length 
of time. In changing to the dorsal posture the patient must ex- 
ercise the greatest caution, and the pillow or cushion must be 
ready to be placed under her the moment she is on her back. 
As soon as this change in position has been accomplished the 
nurse should, with every antiseptic precaution, again insert her 
hand into the vagina to make sure that the cord has remained 
above the pelvic brim. 

It is, of course, assumed that every effort has been made to 
secure the services of some physician, even other than the regular 
medical attendant, before any manual correction of this condi- 



\ NURSE'S HANDBOOK OF OBSTETRICS. 

tion has been attempted by the nurse. If a physician can be se- 
cured within a reasonable length of time nothing should be done 
by the nurse beyond putting the patient in the " knee-chest " or 
the Trendelenburg position and awaiting his arrival. 

During the puerperium the conditions affecting the mother 
which can be classed as accidents and emergencies are eclampsia, 
retained placenta, hemorrhage, and embolism, or " heart clot." 

Eclampsia has already been fully discussed. It must be re- 
membered that it may occur during pregnancy, during labor and 
during the puerperium, but when this complication originates 
after the birth of the child it is of a far less serious nature than 
when it occurs before or during labor. This is known as puer- 
peral convulsion. Under the latter circumstances it may usually 
be relieved by the prompt emptying of the uterus ; but when the 
convulsions appear for the first time after the child is born there 
is nothing to do beyond controlling the convulsions with the 
measures of quiet, rest, diet, elimination, sedatives and oxygen 
and fighting the attack in the manner described. 

The nurse will, of course, summon the physician at once if 
eclamptic convulsions appear, and she must be on her guard that 
the spasms are not due to excessive hemorrhage. There should 
be no difficulty whatever in distinguishing between the two con- 
ditions, for the convulsions due to hemorrhage do not appear 
until the body is practically bloodless and just before death su- 
pervenes, while in eclampsia the patient's face is flushed or 
even cyanotic and the pulse is full and hard. 

Retained placenta is not a serious condition unless the 
presence of the after-birth in the uterus prevents firm contrac- 
tion of the womb and causes severe hemorrhage. Even in these 
cases there is usually time to await the arrival of the physician, 
for it is assumed that he was summoned at the onset of labor, 
and it is not to be supposed that he will leave before the placenta 
is delivered. Firm pressure is to be maintained on the fundus, 
which is to be kneaded vigorously whenever it shows signs of 
relaxation, and it is hardly probable that enough blood will be 
lost to affect the patient seriously. If the bleeding becomes 
alarming, as shown by the amount of the flow and the general 



RETAINED PLACENTA. 263 

condition of the patient, and no physician can be secured, the 
nurse may express the placenta according to the Crede or Dublin 
method. Grasping the fundus, firmly contracted, in the hand, 
the uterus is squeezed and pushed toward the pelvic outlet for 
one or two minutes. The nurse will have seen this manoeuvre, 
and if the placenta does not appear, she will again contract the 
uterus by kneading, take both hands and endeavor again to ex- 
press the placenta. Only a grave hemorrhage can excuse her 
resorting to this method of control. If no physician is as yet 
available and her efforts have proved unsuccessful, she may, 
after the most careful disinfection of her hand and putting on 



Fig. 127.— Manual extraction of the placenta. (Garrigues.) This must never be attempted 
by the nurse, except for urgent reasons and after most careful aseptic precautions. 

boiled rubber gloves, pass it gently into the vagina up to the 
cervix, grasp the placenta firmly in her ringers and remove it 
slowly and with a deliberate twisting motion (Fig. 127). If 
it is still adherent to part of the uterine wall, two or three ringers 
are to be carried into the uterus, between it and the placenta, 
and the tissues separated much as one would separate the sec- 
tions of an orange. When the entire organ has been detached 
in this way, it is to be grasped in the palm of the hand and with- 
drawn carefully. If all antiseptic precautions have been faith- 
fully observed this manoeuvre will do no harm but it must be 
distinctly understood that it is a dangerous thing to do, and one 



264 A NURSE'S HANDBOOK OF OBSTETRICS. 

never to be attempted by the nurse except in the gravest emer- 
gency when no physician at all can be obtained. 

Only once in perhaps a thousand cases will this be necessary, 
and to a nurse, perhaps ten times as rarely. A manual removal 
of the placenta is demanded of her also very rarely and the oft- 
witnessed Crede method, if rightly done, usually succeeds and 
the hemorrhage can be again controlled by efficient kneading of 
the uterus. Care must be taken not to massage the abdominal 
wall, but the uterus itself through the wall. 

Hemorrhage other than the type just mentioned may be 
due to laceration of the cervix or to the uterine inertia. 

Hemorrhage due to cervical laceration is almost invariably 
caused by instrumental or manual delivery, and seldom if ever 
by spontaneous labor. The bleeding appears the instant the 
child is extracted from the vagina, and in rare instances may be 
of sufficient severity to greatly endanger the mother. If the 
fundus is firm and well contracted and the blood continues to 
flow freely, the diagnosis is very simple. 

Fortunately for the nurse, the physician is usually present 
when this accident occurs, and the management of the case rests 
entirely with him. Occasionally it is necessary to bring the 
torn edges of the cervix together with one or two chromicized 
catgut sutures in order to check the bleeding, but in many 
cases snug packing of the vagina with gauze will be found 
effectual. 

Whether the cervix is to be sutured or the vagina merely 
packed, the patient should be turned crosswise in the bed with 
her buttocks well over the edge and her legs supported in the 
lithotomy position, either in a leg holder or by assistants. 

If packing is the method of treatment employed, the nurse 
must watch the fundus with special care during the next few 
hours, lest hemorrhage continue into the cavity of the uterus. 
The packing should never be left in the vagina for more than 
twenty-four hours, and in many cases it is better to remove it 
at the end of twelve hours, as it almost invariably interferes 
with natural urination and makes catheterization extremely 
difficult. 



POST-PARTUM HEMORRHAGE. 265 

If the hemorrhage has been at all severe the nurse should 
prepare hot sterile normal salt solution (one teaspoon ful to the 
quart) for infusion, arrange for elevating the foot of the bed, 
and provide an ample number of hot-water bottles (beer-bottles 
with patent stoppers in an emergency) with which to surround 
the patient. 

Post-partum hemorrhage, in the ordinary acceptance of 
the term, is that which occurs from the cavity of the uterus after 
the birth of the child and either before or after the delivery of 
the placenta. It is due in almost every case to relaxation of 
the uterus (uterine inertia), and may usually be prevented if 
proper attention is paid to the management of the fundus during 
the hour that immediately follows the delivery of the infant. 

It is apt to occur in severe cases of albuminuria or other 
constitutional disturbance ; it frequently follows operative de- 
livery or prolonged and exhausting natural labor; and it may 
occur in any case from no discoverable cause, unless it be care- 
lessness in holding the fundus. Consequently, the occurrence 
of post-partum hemorrhage is to be regarded as a possibility 
after every case of labor, no matter how simple and normal its 
course may have been, and, as Dr. Gooch has said, " No physi- 
cian should have the assurance or hardihood to cross the thresh- 
old of a lying-in chamber who is not thoroughly conversant with 
the remedies for flooding." 

Unfortunately, there are many physicians who, although 
they may be as " thoroughly conversant with the remedies for 
flooding " as Dr. Gooch in his most exacting mood could desire, 
neglect systematically to provide themselves with the necessary 
drugs and appliances to meet this condition effectively. Nearly 
every case of post-partum hemorrhage that passes beyond con- 
trol may be accounted for by the neglect of some one to have 
ready the necessary articles for checking it at its very outset, 
and it may safely be said that there is no variety of hemorrhage 
that should be so amenable to the surgeon's skill as the one 
under consideration. 

The physician who attends obstetric cases with no other 
equipment than a vial of ergot, a bichloride tablet, and a pair 



A NURSE'S HANDBOOK OF OBSTETRICS. 

of forceps in a little black bag is rapidly being relegated to the 
obscurity which he deserves, and his disappearance from society 
will be of untold benefit to the mothers of the future. 

Post-partum hemorrhage is usually external, or largely so, 
but when it occurs before the delivery of the placenta it may, 
in good part, be concealed within the cavity of the uterus. The 
concealed type can never occur if the fundus is properly held, 
for the blood will necessarily be squeezed out of the uterus into 
the vagina and escape. 

When, however, the uterine tissue is so inert that, although 
it may be compressed and the walls of the uterus approximated 
by the pressure on the fundus, the muscular fibres refuse to con- 
tract and close the blood-vessels, the condition is a most alarm- 
ing one, and in severe cases may cause death within a few 
minutes. 

As a rule, if hemorrhage does not occur within an hour after 
the birth of the child, especially when the fundus has been 
properly managed, it will not occur at all, but it may develop 
twenty-four hours or even longer after delivery, and the nurse 
will be called upon to meet the emergency without a moment's 
delay ; for the greatest factor in its control lies in the promptness 
with which it is met. 

In cases which occur before the departure of the physician 
he will usually pack the uterus firmly with strips of sterile gauze, 
if the administration of ergot, vigorous kneading of the fundus, 
and a hot (120 F.) sterile or saline douche do not check the 
flooding at once. Every physician should have gauze for tam- 
poning the uterus in his maternity outfit, and the nurse should 
have ready, at every labor, a sufficient quantity of hot sterile 
water or saline solution for use at a moment's notice. It is easily 
prepared and may be preserved sterile in Mason jars. 

The patient is to be brought to the edge of the bed, in 
the lithotomy position, and if the physician decides to pack 
the uterus he will grasp the anterior lip of the cervix with a 
volsellum or bullet-forceps, draw it down to the vulva, and 
have the nurse steady it in this position while he inserts the 
gauze. Hot salt solution for infusion or rectal irrigation must 



POST-PARTUM HEMORRHAGE. 267 

be provided at once, the patient laid flat on her back, without a 
pillow, and surrounded with hot-water bottles, the foot of the 
bed elevated, and hot water with whiskey or brandy given by the 
mouth unless there is vomiting. 

If hemorrhage occurs when the nurse is alone, she should, 
of course, send at once for the first physician that can be 
reached. 

In many cases her attention will be directed to the condition 
by the patient herself, who will complain that she is " flooding," 
and inspection will show a pool of blood (possibly a pint or 
more) in the bed. At other times the suspicions of the nurse 
will be aroused by the pallor of the patient's face, and on 
raising the bedclothes the evidences of severe bleeding will be 
found as before. 

The first thing to do, after sending a messenger hastily for 
the nearest physician, is to grasp the fundus, if it can be found, 
and knead it energetically. If ergot is to be had, some one 
should be directed to give the patient a teaspoonful by the mouth. 
If the nurse has equipped herself according to the directions 
given, she will be prepared for any emergency. The vigorous rub- 
bing of the fundus is to be kept up while some one is despatched 
for hot water and salt, and, if a piece of ice can be secured 
promptly, it may be rubbed briskly over the belly to stimulate 
uterine contraction while awaiting the arrival of the hot water. 

As soon as the materials for the douche are at hand the water 
is to be brought to the temperature of 120 F. (or as hot as the 
hand can bear) by the addition of cold water if necessary, a 
teaspoonful of salt added to each quart, and the solution in- 
jected freely into the uterus, while the hand on the abdomen still 
exerts pressure on the fundus. 

This saline douche will serve in emergency, but emphasis is 
again laid upon the aseptic preparations which should be made 
for just this emergency. If the hot douche, continued, and the 
vigorous manipulation of the fundus with the nurse's left hand, 
and stimulation of ice cloths upon the lower abdomen, still fail 
to control; if ergot, 30 to 60 minims, and repeated in fifteen 
minutes has failed; if it has proven impossible to secure the at- 



268 A NURSE'S HANDBOOK OF OBSTETRICS. 

tendance of a physician, the only remaining hope is to pack the 
uterus. 

The nurse cannot be expected to do this as expeditiously or 
as effectively as the physician, but if she has in her the stuff that 
heroines are made off, and keeps cool and collected, she may, in 
a desperate case, be the means of saving a life that would other- 
wise inevitably be lost. She will not have proper materials for 
packing nor instruments for the introduction of the tampon, but 
there is no time to be lost and she will have to do the best she 
can. If she has plain gauze, well and good. She has been told 
to provide herself with a jar of gauze for just this emergency, 
to avoid the desperate chance taken where unsterile material 
must be used. She uses all aseptic precautions, has the jar held 
close to the vagina, cleanses the external genitals, puts on 
gloves and using her forceps while the uterus is held down from 
above, so that the cervix will appear at the vulva, she will pack 
quickly in loops of about six inches at a time, until the cavity is 
entirely filled, after which the vagina is to be packed with equal 
firmness. Care must be taken not to do injury with the forceps. 

She is guilty of criminal neglect if she is not provided with 
uterine packing for a post-partum hemorrhage. Doctors answer- 
ing calls do not always possess information as to the patient's 
condition, but nurses who are left in charge of patients of a 
character making a hemorrhage always a possibility are not free 
from blame if their bag does not provide for such an emergency. 
If she is not ready, as her patient has the right to expect her to 
be, and depends upon her being, she will have to take a clean 
sheet, tear it into strips three inches wide and as long as the ma- 
terial will allow. She can usually buy a sterile bandage three 
inches wide. She proceeds as described. It is, of course, as- 
sumed that the rules of surgical cleanliness will be followed as 
far as the circumstances will permit, but in those cases where the 
question of life or death must be decided within a very few 
minutes the hemorrhage must first be controlled at any cost and 
the septic infection, if it occurs, combated afterwards. 

As soon as the uterus and vagina are packed the patient is to 
be placed on her back with no pillow, surrounded with hot-water 



POST-PARTUM HEMORRHAGE. 



269 



bottles, and the foot of her bed elevated, a quart of hot salt solu- 
tion (118 F.) is to be injected slowly into her rectum, as high 
up as possible, to be absorbed and take the place of the blood 
lost, and this may be repeated every half-hour if necessary or a 
Murphy seepage apparatus may be used. 

Stimulation, in the form of whiskey, one drachm, strychnine, 




Fig. 128. — Murphy saline drip apparatus. Observe hot-water bottle of metal. The 
solution runs through the rubber tube from the can, and is heated by the hot water in the 
metal bottle. The gas from the rectum is expelled through the tube into the can. 

one-sixtieth grain, or nitroglycerin, one one-hundredth grain, is 
to be given hypodermically as indicated; and it may be helpful 
to force the blood out of the extremities into the trunk by band- 
aging the legs. These bandages should never be allowed to re- 
main for more than two hours, and they are to be removed with 
great caution, one at a time, to avoid the danger of collapse. 

If the patient still fails to respond to treatment, subcutaneous 
infusion of normal salt solution should be performed as follows ; 
A pint of the solution, at a temperature of ioo° F., is placed in 
an ordinary irrigator and hung about three feet above the level 



A NURSE'S HANDBOOK OF OBSTETRICS. 

of the patient's body. An ordinary hypodermic needle (the 
larger the better), or, best of all, an aspirating needle (Fig. 129) 



Fig. 129. — Aspirating needle. 



is attached to the end of the tubing, and as soon as the liquid 
begins to flow the needle is thrust for its entire length into the 
chest at the base of the breast, parallel to the surface of the body 
or on the anterior aspect of the thigh. Gentle massage should be 
practised as the solution distends the tissues, and the needle 
should be moved about from time to time and occasionally with- 
drawn and inserted in a new place. The time required for the 
infusion of a pint of solution in this manner will be from ten to 
twenty minutes according to the size of the needle, and fresh 
hot solution should be added at occasional intervals to keep the 
temperature up to the required point (100 ). 

It is needless to say that the apparatus and the solution must 
be sterile, and the skin at the site of the infusion is to be wiped 
off with alcohol, and painted with tincture of iodine, the punc- 
ture protected from infection by towels and sealed with cotton 
and collodion or sterile adhesive. The nurse must not fail for 
an instant to exercise firm pressure upon the perineal pad with 
one hand, and with the other hand to exert pressure upon the 
fundus. 

The method of treatment outlined here is carried to com- 
pletion to cover those cases in which no physician at all can be 
secured, but the nurse must exert every effort to obtain the 
services of some medical man at the earliest possible moment 
who will take charge of the case and relieve her of any further 
responsibility. 

Although a condition that is preventable in almost every 
properly managed case, post-partum hemorrhage is one of the 
most terrible complications that can arise in any branch of sur- 
gery, and the nurse who can, by her own efforts, bring a patient 
out of this emergency is worthy of all honor and respect. 



EMBOLISM. 



271 



Embolism, or " heart clot," may be formed originally in the 
right ventricle, or may be due to a thrombus which is washed 
along in the blood-current until it is lodged in the heart. The 









Fig. 130. — Hypodermoclysis. A rubber bag should not be used for this. An irrigating 
can or a regular infusion apparatus is necessary. The solution must be sterile. 

clot obstructs the passage of blood into the lungs, either wholly 
or in part, and the patient may die of asphyxia within a few 
minutes. 



A NURSE'S HANDBOOK OF OBSTETRICS. 

The condition may follow severe hemorrhage, septic infec- 
tion, shock, or general exhaustion, and may occur at any time 
during the puerperium. 

The entrance of air into the circulation through the uterine 
vessels, either from the careless administration of a douche or 
from the decomposition of septic matter within the uterus, pre- 
sents practically the same symptoms and calls for the same treat- 
ment as heart clot. 

The symptoms are sudden, severe pain over the heart, great 
dyspnoea, syncope, feeble, irregular pulse, or none at all, pallor 
in some cases and cyanosis in others, and death at any time 
within a few minutes to a few hours, according to the amount 
of obstruction to the pulmonary circulation. Very few cases 
recover. 

The treatment consists, first in preventing the accident by 
careful attention to all details in the proper management of 
every obstetric case, and secondly, if the complication arises, in 
the free administration of whiskey and strychnine and the main- 
tenance of absolute quiet on the back, for the slightest move- 
ment may result fatally. 

If the patient survives the attack, the body temperature must 
be kept up by the use of hot-water bottles, absolute rest en- 
joined, and a light, nourishing diet given, in the hope that she 
can be kept alive until the clot is absorbed. 

The only obstetric emergency that can affect the child after 
its birth is secondary hemorrhage from the navel or cord. 

If the blood escapes through the vessels of the cord before 
it has separated from the body, a fresh ligature is to be applied 
and tied tightly and carefully. 

If the blood comes from the navel itself at the base of the 
cord, either before or after its separation, it can usually be 
controlled by firm pressure with hot compresses (no° F.) until 
the arrival of the physician. The treatment which he will prob- 
ably adopt if the hemorrhage is severe and continues for a long 
time is to transfix the base of the navel with two long needies 
inserted at right angles to each other and compress the vessels 
against them with a tight " figure-of-eight" ligature. 



EMBOLISM. 273 

In rare cases, where no physician can be secured, the nurse 
may have to do this herself. Every antiseptic precaution is to 
be faithfully observed, and the needles (darning needles will 
answer) and silk or bobbin tape must be boiled. 

The navel is to be pinched up with the thumb and forefinger 
and a needle thrust through its base from side to side at a 




Fig. 131. — Figure-of-eight ligature. For controlling secondary hemorrhage from the 

umbilicus. 

depth of about one quarter of an inch. The second needle is 
then to be inserted in the same manner, at right angles to the 
first, and the ligature passed tightly over the ends in " figure-of- 
eight" loops and drawn up until every vestige of bleeding, or 
even oozing, has ceased (Fig. 131). The needles may be re- 
moved at the end of six or eight hours, but the ligature should 
be allowed to remain and come off when it will. 

The dressings should be changed daily and the most rigid 
antiseptic precautions must be observed until the parts are 
entirely well. 

While the nurse should, of course, make every possible 
effort, both by study and training, to so prepare herself that 
she may be always ready to cope with the unexpected in 
obstetric or other surgical practice, it must be constantly borne 
in mind that technical perfection alone will avail little or 
nothing in such crises unless it is coupled with absolute cool- 
ness of head and promptness of action together with the 
exhibition of no small amount of good, old-fashioned, common 
sense. 
18 



XX 

Pathology of the Puerperium 

The disorders of the puerperium are: puerperal fever, in 
its various forms; phlegmasia alba dolens, or "milk leg"; 
diseases of the nipples and breasts and insanity. 

Puerperal fever, also known as puerperal septicemia and 
" child-bed fever," is a condition always due to infection from 
without, and this infection may, and usually does, result from the 
introduction of bacteria into the genital tract at the time of the 
labor, either by the hands or instruments of the physician, or 
after labor, by surgical uncleanliness on the part of the nurse, 
whether in the use of the catheter or in her general care of the 
patient. In detail it may be said that infection may be introduced 
by anything not sterile. The preparations for labor, the technic 
during confinement, the lack of systematic methods of nursing 
during the puerperium, all tend to swell the total number of 
deaths, and invalids, from this nearly always preventable cause. 

In rare instances the infection may be due to a septic in- 
flammation of the vagina or other pelvic organs which exists at 
the time of the labor and extends to the interior of the uterus 
or to other tissues after the birth of the child. 

The usual point of entrance for the septic germs is at the 
denuded placental site in the uterus, where the tissue is damaged 
and bacteria can easily find a way into the system, but any other 
raw surface, such as a laceration of the cervix or perineum, may 
afford an equally good starting-point for the disease. 

There are several varieties of puerperal fever, each of which, 
in its typical form, presents a very characteristic set of symp- 
toms, but it not infrequently happens that one form of the disease 
will eventually develop into another and more severe kind. The 
distinctions between these different types are, of course, of in- 
terest and importance to the physician, for not only the treat 
274 



PUERPERAL FEVER. 275 

merit but the prognosis depends upon the particular form of in- 
fection from which the patient suffers. 

It may be said that the nature of the bacteria, their number, 
and the patient's power of resistance are the factors determin- 
ing the virulence of the infection. 

As far as the nurse is concerned, however, it is only necessary 
to be able to recognize at once the onset of the disease in order 
that the physician may be notified immediately and proper treat- 
ment instituted without delay. 

Puerperal fever usually develops about the third or fourth 
day after delivery, but its onset may be postponed until the 
eighth, ninth, or even tenth day. As a rule, however, if there 
are no symptoms by the end of the first week none will appear 
at any time. The cases that develop after this period are rare, 
are often due to infection introduced by the catheter or other- 
wise several days after delivery, and are seldom of sufficient 
severity to endanger the patient's life, although they may seri- 
ously affect her general health for months or even years. 

The patient first complains of malaise, headache, backache, 
and general discomfort. This is soon followed by a distinct 
chill, or, occasionally, only by chilly sensations, and the ther- 
mometer shows a considerable rise of temperature, often as high 
as 105 or 106 F. In the severe cases the pulse becomes rapid 
and feeble and may be irregular, and the patient's face is pale 
and anxious. The tongue is at first heavily coated, but later 
becomes brown and dry, and the lips are covered with sordes. 
The lochial discharge stops, or it may become dark and very 
offensive. The abdomen is soft and usually slightly tender over 
the uterus, but there is no actual pain or tympanites unless 
general peritonitis develops as a complication. Vomiting may 
or may not occur, and severe diarrhoea is very common. The 
urine is scanty, high colored, and may contain albumin, and if 
the secretion of milk has begun it ceases. The patient has alter- 
nating delirium and stupor, followed by coma, and death may 
occur within a few days. 

These symptoms belong to the most severe type of puerperal 
fever, in which the infection, beginning in the uterus, extends 



276 A NURSE'S HANDBOOK OF OBSTETRICS. 

rapidly throughout the entire system. In the milder cases, where 
the infection is less virulent, or where it is confined to the 
uterus itself or to lacerated tissue in the cervix, vagina, or 
perineum, the symptoms are not so pronounced, and the patient 
usually recovers, although she may be transformed into a con- 
firmed invalid or, at least, remain sterile the rest of her life. 

The treatment, of course, rests entirely with the physician, 
and usually consists in the thorough exploration of the interior 
of the uterus and the removal of any placental tissue, clots, or 
other foreign matter that may be present and undergoing decom- 
position. This is, in many cases, all that is required, and the 
careful emptying and douching of the uterine cavity is followed 
by an immediate fall in temperature and improvement in every 
way. More often, however, it is thought necessary to perform 
a thorough curettage under ether in order to remove every par- 
ticle of infected tissue from the uterine wall, and not a few phy- 
sicians adopt this method at the outset rather than take any 
chance with less radical treatment. 

As the prompt institution of measures to check the disease 
is of the greatest importance, the nurse must always be on the 
alert to recognize any one of the initial symptoms of puerperal 
fever the moment it appears and report it at once to the phy- 
sician. Headache, backache, malaise, or any feeling of discom- 
fort must not be overlooked, and a rise of temperature over 
100.5 ° F. or pulse over 100 should be brought to the physician's 
notice without delay. 

These premonitory symptoms may not indicate puerperal 
fever, as they occur at the onset of almost any acute disease, but 
they are sufficiently significant to warrant immediate attention, 
and the nurse must never lay herself open to the charge of hav- 
ing neglected to recognize, and report to the physician in charge, 
any change in the patient's condition which might be indicative 
of danger. 

After the genital tract has been thoroughly cleansed of all 
foreign matter the treatment consists solely in fighting the con- 
stitutional effects of the disease with tonics, stimulants, and nou- 
rishing diet. Crede's ointment (unguentum Crede), a prepar- 



PUERPERAL FEVER. 277 

ation of metallic silver used by inunction, has been highly recom- 
mended as a specific by some authorities ; the subcutaneous in- 
jection of hot normal salt solution often seems to give good 
results ; and, in those cases due to infection by the streptococcus, 
the antistreptococcic serum (streptococcus antitoxin) has been ad- 
ministered hypodermically with alleged benefit ; but none of these 
methods has the unqualified approval of all physicians, and suc- 
cess can only be expected to follow a judicious combination of 
several of the recognized means of fighting the disease. 

The story of the discovery of the cause of puerperal sepsis 
has been made familiar to the laity by popular magazine writers, 
and the average mother is aware that some one is probably 
grossly guilty if any such condition develops. Barely sixty years 
ago Semmelweiss in Austria and before him Oliver Wendell 
Holmes of Boston, endeavored to prove that it was a " private 
pestilence " and the Austrian proved in his own hospital prac- 
tice that the infection within came from the introduction of in- 
fection from without. Only forty years ago the whole field 
of bacteriology was opened and the world is now converted to 
a standard of cleanliness that has made a case of puerperal 
sepsis a crime upon the head of the person responsible for it. 

It is a disease of great antiquity and strangely enough is still 
prevalent. Being a preventable disease, the number of deaths 
annually is a sufficiently serious reminder to a nurse of the duty 
she owes to the world and herself in the care of an obstetrical 
case. Again it may be said that obstetrical nursing demands a 
nurse of a superior order. In the United States there were re- 
ported 6000 deaths in one year from this cause, and in New York 
City the unbelievable total of 407 cases. Nurses should, there- 
fore, be alert and emulate in private practice the records of hos- 
pitals, in which the development of a case of sepsis is practically 
unknown. 

Phlegmasia alba dolens {"milk leg") is a disease of the 
puerperium characterized by pain and swelling in the affected 
limb due to the formation of a clot in the veins of the leg itself 
or in those of the pelvis, interfering with the return circulation 
of blood. It is due to septic infection extending from the uterus 



j;S A NURSE'S HANDBOOK OF OBSTETRICS 

to the veins of the pelvic, and thence clown the leg, and usually 
appears about two weeks after labor, the most common time 
being on the eleventh or twelfth day. 

The disease is ushered in with malaise, chilliness, and fever, 
which are soon followed by stiffness in the affected leg and pain, 
usually in the groin. The leg now begins to swell, either from 
above downward or from below upward, and in a few hours is 
so tense and exquisitely painful that the slightest movement 
causes intense suffering. 

The acute symptoms last a few days or a week, after which 
the pain gradually subsides and the patient slowly recovers. 

The course of the disease covers a period of from four to 
six weeks, and the affected leg seldom returns to its normal size, 
but remains permanently enlarged. 

The prognosis is usually favorable, although in some of the 
very severe cases abscesses form and the disease may become 
very critical or even prove fatal, while in very rare instances the 
clot may be dislodged and carried to the heart, causing instant 
death. 

The treatment consists in absolute rest, the use of ice-bags 
along the course of the affected vessels, and morphine as in- 
dicated for the pain. Some physicians apply warm wet dressings 
covered with cotton and oil silk or rubber. The heat is main- 
tained by electric coils or hot-water bottles. These dressings are 
applied well inside the thigh. The pain is lessened by elevation of 
the limb by means of a pillow, and pressure from bed-clothing 
is prevented by use of a cradle. Under no circumstances should 
a nurse rub or massage such a swelling; and the limb must be 
handled with the utmost care when changing dressings, applying 
a bandage or giving a bath. The patient's own movements must 
be guarded, and assistance must be given by the nurse. Skilful 
care is required to preserve the tissues of the body in good con- 
dition, as recovery is usually tedious. As the acute stage sub- 
sides, general tonics, nourishing food, and the most carefully 
regulated hygienic conditions are needed to build up the patient's 
strength. 

As in all acute febrile diseases occurring after labor, the se- 



DISEASES OF THE NIPPLES AND BREASTS. 



279 



cretion of milk ceases when phlegmasia alba dolens is developed, 
and the physicians of many years ago gave to the disease the 
name of " milk leg," in the absurd belief that the condition was 
due to a secretion and collection of milk in the affected limb. 
So firmly was this impossible idea fixed in the minds of woman- 
kind that to this day the expression " milk leg " is in common 
use among the laity. 

Diseases of the nipples and breasts. Any slight erosion 
of the nipple may be aggravated by nursing until an actual fis- 
sure is formed. The fissure will cause great pain at each nursing 
period, and the pain may be enough to absolutely prevent suck- 




FlG. 132. — Tray with everything needed for the care of the breasts. 

ling at the affected breast. This may cause congestion of the 
gland, and, as the surface of the fissure offers an ideal entrance 
for bacteria, septic inflammation or abscess of the breast may 
result. Even when septic infection does not occur, the pain may 
seriously affect the secretion of milk and, in highly nervous or 
hysterical women, cause a slight rise of temperature and retard 
involution of the uterus and its adnexa. 

If nursing is impossible the child is deprived of its proper 
food, while if nursing is continued in spite of the pain the pro- 
teids of the milk are apt to be increased, and the discharge from 
the eroded surface is extremely bad for the baby. Hence it will 
be seen that this condition, trivial though it may appear at first 



2 8o A NURSE'S HANDBOOK OF OBSTETRICS. 

thought, exerts a most harmful influence on both mother and 
child. 

The first symptom of erosion or fissure of the nipple is pain 
at the time of nursing, and careful inspection of the part will 
at once disclose the true nature of the trouble. 

The treatment includes the preventive measures to be adopted 
during the last two or three months of pregnancy. These 
already discussed, consist in bathing the breasts night and morn- 
ing with cold water, and softening the crusts of colostrum with 
albolene, and removing them every day, so that the delicate tissue 
of the nipple will not be injured by the presence of these hard 
deposits. If these precautions are carefully followed the nipples 
will be in good condition when the infant begins to nurse, and 
no trouble will be likely to ensue. 

The treatment after the condition has developed rests with 
the physician, and the nurse should report to him at once if the 
nursing is painful or if any eroded surfaces are noticed. The 
usual treatment consists in cleansing the parts thoroughly and 
applying a solution of nitrate of silver (forty grains to one 
ounce) with a fine camel's-hair brush to the diseased surfaces, 
after which the nipple is dusted with some simple antiseptic 
powder, such as aristol, and nursing stopped on the affected 
side for twenty-four hours. 

A considerable quantity of milk will collect in the breast 
during the time in which nursing is stopped, and this must be 
removed with the breast-pump or by massage. Massage of 
the breast when merely for the purpose of removing an exces- 
sive quantity of milk is done in the following manner. There 
are four distinct steps in the emptying of the breast, each of 
which must be practised carefully and intelligently in order to 
secure a good result with the least amount of pain. The breast 
is first cleansed gently with soap and warm water, and then 
anointed with warm camphorated oil or albolene. The hands 
of the nurse must also be disinfected with the utmost care 
and the fingers should be dipped in the oil or other lubricant to 
be used. 

The first step (Fig. 133, A) consists in grasping the breast at 




5^^^jW|Pif~ ' ^w^ 




Fig. 133. — Massage of the breast. 



MASSAGE OF THE BREAST. 2 8l 

its periphery with the fingers separated as widely as possible, 
and then drawing them towards the nipple with a firm but 
gentle pressure. The entire breast is to be gone over in this 
manner and the fingers are to be brought together as the nipple 
is approached, and this manoeuvre is to be kept up for at least 
five minutes, by the end of which time the breast should be 
fairly soft and the milk flowing freely. 

The second step (Fig. 133, B) consists in placing one hand, 
palm upward, under any indurated or " caked " portion of the 
breast, and with the fingers of the other pressing downward 
towards the supporting hand and forward towards the nipple. 
Each indurated spot is to be treated in turn in the same man- 
ner until all are soft. 

The third step (Fig. 133, C) consists in pressing downward 
against the chest wall with the flat of the hand over any hard- 
ened areas that may remain. The pressure should be greatest 
on the side of the hand next to the periphery of the breast, and 
should gradually increase towards the nipple with a sort of 
rocking motion. This is followed by a rotary motion of the 
palm of the hand over the induration, continued until no further 
softening can be accomplished. 

The fourth step consists in grasping the entire breast in both 
hands and squeezing out whatever milk remains. 

Massage of the breast must always be practised with the ut- 
most gentleness, for fear of injuring the delicate structures of 
the gland, and, in the manner described, it should never be es- 
pecially painful if it is properly performed. Any roughness in 
the manipulation may cause damage to the tissues and result in 
the formation of an abscess. 

Breasts are never to be massaged or pumped except by order 
of the physician in charge. So much serious damage may be 
clone by unintelligent failure to recognize conditions that it is of 
the utmost importance that the breast be let severely alone so 
far as expression of milk is concerned until definite orders are 
received. The utmost surgical cleanliness is essential, as hands 
soiled with lochia or the colon bacillus are sure to accomplish 
mischief. The nipple itself is never to be touched with the fingers. 






282 A NURSE'S HANDBOOK OF OBSTETRICS. 

In applying the nitrate of silver solution to the fissure the 
nurse must separate the edges as widely as possible and touch only 
the denuded tissue of the fissure with the tip of the brush. Care- 
lessness in the use of the solution not only smears the breast with 
a black dirty looking stain, but also causes more or less irritation 
to the surrounding parts. 

When the fissure does not heal sufficiently by the end of 
twenty-four hours to permit of painless nursing, it may be ne- 




123 12 

Fig. 134. — The nursing bottles and rubber nipples at the left are practical. The hor- 
izontal bottle is excellent. The English breast pump is good. The nipple shield, marked 
1, is the best, 2 is poorly constructed. The lead nipple shield is known as Wansbrough's. 
The lactic acid is supposed in combination with the leaden shield to cure cracked nipples. 

cessary to use a nipple shield for a few days, and this will always 
be the case when both breasts are affected at the same time, unless 
the child is given artificial food while the process of repair is 
going on. The shield must be sterile, and after being used it 
should be scrubbed clean, boiled and kept in a dry sterile Mason 
jar as immersion in boric or saline solutions soon renders rubber 
nipples useless. 

The shield must be applied to the nipple with the utmost 
gentleness, and before the child is allowed to nurse, enough milk 
to fill the glass part of the shield must be expressed into it by 



INFLAMMATION OF THE BREAST. 283 

massaging the breast for a few moments. If this is neglected 
the infant will get little or no milk at all, while, on the other 
hand, he will suck in a quantity of air which will distend his 
stomach and cause colic. 

The nipple shield must never be placed on the breast in such 
a position that when suction begins the edges of the fissure will 
be drawn apart, and in certain cases, such as fissure at the base 
of the nipple, it will do more harm than good. 

The shield is always to be used with the greatest caution, and 
must at all times be kept in a perfectly aseptic condition. As 
the majority of fissures will, under proper treatment, heal com- 
pletely in twenty- four hours, it seldom happens that the use of 
the shield is necessary, and when, for any reason, it must be 
employed, it should be laid aside the moment that it can be dis- 
pensed with. 

The treatment outlined here is varied by different physicians. 
The use of castor oil, bismuth and collodion in different com- 
binations, glycerine, compound tincture of benzoin and the appli- 
cation of a Wansbrough leaden shield, all find advocates. 

If the nipples are in a healthy condition the mother should 
never be allowed to use the shield merely to avoid the discomfort 
caused by the suckling of a vigorous child. 

Mastitis (inflammation of the breast) may be of any grade, 
from a simple congestion to a suppurative process that results in 
the formation of multiple abscesses in the glandular tissue. 

The cases of simple congestion may be due merely to over- 
secretion of milk and consequent distention and congestion of 
the mammary gland, but those accompanied by suppuration are 
always due to septic infection which enters usually through a de- 
nuded or diseased nipple. 

Distention of breast: About the third day the congestion or 
distention of the breast is apt to cause intense pain. It is not 
altogether due to the amount of pressure caused by increase in 
the milk supply, but is chiefly caused by glandular swelling and 
by engorgement of the blood-vessels and lymph-spaces around 
the glands. The tenderness to touch is extreme, and nursing 
is perhaps impossible. For the heavy enlarged breasts, the usual 



284 A NURSE'S HANDBOOK OF OBSTETRICS. 

treatment is a tight, snug, padded binder. Physicians usually 
prescribe salines to lessen the venous and lymphatic engorgement 
and the application of ice-bags or a continuous wet hot dressing 
to the breasts. Nurses must excel in carefulness here. The 
breast pump and massage are not to be used unless ordered, as 
infection may be present. This condition of simple distention 
is not attended with fever (fever would indicate infection). 
The discomfort is great, but it subsides in a few hours. 

If the infant is weak the milk may have to be expressed, and 
the breast massaged gently for a few minutes. Stimulation 
other than nursing of the infant is to be avoided. 

There are four periods when mastitis is especially liable to 
occur, but it may make its appearance at any time during lacta- 
tion. The periods of greatest frequency are during the first 
month, and especially the first fortnight after birth, when the 
nipples are tender and not accustomed to nursing; whenever 
nursing is suddenly stopped (as, for example, on account of the 
death of the child) and the breast becomes engorged with milk; 
at the time when the infant cuts its teeth and the nipples are 
again exposed to injury ; and at the end of lactation, either be- 
cause of hypersecretion of milk due to careless management when 
the infant is weaned, or because the child, being dissatisfied with 
the quality or quantity of the milk, shows its displeasure by biting 
or gnawing the nipple until it is injured and sore. 

This infection is rarely, if ever, caused by the amount or 
stagnation of milk, but, as has been said, by infection through a 
nipple, which may be diseased as well, or an infected suppurating 
Montgomery gland. The necessity for a continuous exercise of 
asepsis in the care and covering of the nipples is evident, Their 
condition, their care, the amount of mechanical injury inflicted 
by the infant, and the condition of the mother are all factors 
entering into the probable outcome of a septic infection. 

The first symptoms of mastitis are a feeling of discomfort 
and pain in the breast, followed by chilliness or a distinct chill 
and a sharp rise of temperature to 105 ° or 106 F. Inspection 
shows that the gland is tense, hard, nodular, red, and exquisitely 
painful. 




Fig. 135.— Author's breast-binder. 



INFLAMMATION OF THE BREAST. 285 

If treatment is begun at once, it may be, and often is, pos- 
sible to check the disease at the outset, but to accomplish this 
result energetic measures must be resorted to without delay. 

The physician must be notified immediately, and if there 
promises to be a wait of several hours before his presence or 
his advice can be secured the nurse may properly proceed as 
follows : 

A snug breast-binder (Fig. 135) is applied and, after it is 
pinned, holes about the size of a half-dollar are cut over each 
nipple to allow the milk to escape. This can be done by picking 
up the material directly over the nipple with a thumb forceps, 
drawing it well away from the body, and cutting through it 
with scissors, after which the opening is carefully enlarged to 
its proper size and shape. If a piece of cotton is laid over each 
nipple before the binder is applied, there will be no difficulty what- 
ever about grasping the muslin, and after the hole is cut the 
cotton may be left until it is soaked with milk, when it is to be 
removed and fresh pieces inserted. Ice-bags are now placed 
over the inflamed area and left until all inflammation has sub- 
sided or until the physician orders their removal. These ice- 
bags must be lightly filled with slush ice and applied to secure 
cold to the gland. They may be supported by small pillows at 
either side. If one breast only is infected a roller bandage or 
a Boston Lying-in-Hospital binder may be ordered. The patient 
frequently complains of chill under this treatment. She should 
be in bed and external heat applied. The bowels are best moved 
with a saline cathartic, such as magnesium sulphate (Epsom 
salt), one-half ounce in half a glass of water. 

Nursing must, of course, be stopped at the affected breast, 
and the ingestion of fluids is to be restricted as much as possible 
until all the symptoms have disappeared. 

This treatment, if begun at once, is usually successful in 
checking the disease, but, as has been said, it must be instituted 
without a moment's delay if it is to be effective. The inflamma- 
tion, under the treatment of rest, tight bandaging and ice-caps, 
with salines, usually subsides at the end of a day or two, and 
nursing is resumed. A doctor may attempt to avert the incision 






28 i 



A NURSE'S HANDBOOK OF OBSTETRICS. 





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PUERPERAL INSANITY. 287 

in deep-seated infections by the the use of the Bier congestion 
bell. This is applied as often as is ordered for short periods of 
time, but because of the pain involved in comparison with the 
treatment outlined, it is but little used in practice. 

If the treatment outlined above is unsuccessful and the case 
goes on to suppuration, the treatment is necessarily surgical, and 
the nurse can only follow the directions of the medical at- 
tendant. 

Local anaesthesia is generally given and the incision made as 
small as possible. Evacuation of the pus is sometimes difficult 
to secure. The drain is perhaps a small wick or may be some 
form of suction cup, depending upon the area involved. This 
implies the necessity at times for an anaesthetic at dressings. 
It is not necessary to repeat the caution concerning the handling 
of such pus. Gloves and gown to protect nurse and both pa- 
tients ; cleanliness and good technic are demanded. 

It may be said that the cases of mastitis that develop during 
the first month after labor seldom go on to suppuration, but 
those appearing later in the puerperium are very likely to do so 
unless they can be checked in the manner described. 

Syphilitic lesions may be found on the nipple, either primary 
from the bite of a syphilitic child, or of the tertiary type in a wo- 
man who is suffering from the disease in its advanced stage. The 
matter would, of course, be brought at once to the attention of 
the physician, and the treatment is the same as it would be 
under any other condition. 

Eczema of the nipple and areola, and occasionally extending 
over the entire breast, is a rare complication that may arise 
during the puerperium. Its treatment is both local and general, 
and can only be carried out by the physician. 

Insanity may occur at any time after conception and disap- 
pear within a few days or even hours, or it may continue through- 
out the entire pregnancy, into the puerperium, and even through 
the whole period of lactation. 

The insanity of pregnancy is usually melancholia, and is often 
so slight that it is entirely unnoticed, but it may, on the other 
hand, be very pronounced, with a marked suicidal tendency. 



2 88 A NURSE'S HANDBOOK OF OBSTETRICS. 

The insanity of the pnerperimn, called "puerperal insanity," 
is most often of the maniacal type, and is the most common of 
the three varieties. The mania usually appears within a month 
after delivery, either following the melancholia of pregnancy or 
without any warning whatever. The patient is at first restless 
and disagreeable, and soon evinces a marked dislike for her 
husband and others who are most nearly related to her, or else 
the mania develops suddenly with no premonitory symptoms. 
The woman becomes noisy, talkative, and incoherent, and her 
mind may dwell on religious subjects, or she may be profane, 
obscene, and vulgar, with an absolute loss of all sense of decency 
or modesty. The tendency to suicide or murder is always 
strongly marked, and the patient must be most carefully watched. 

The insanity of lactation is usually of the melancholic type, 
like that of pregnancy, and is most commonly seen in multipara? 
who have borne many children in rapid succession and whose 
general condition is greatly impaired. 

The causes of insanity cannot be stated very definitely, but 
may be supposed to include all conditions that greatly under- 
mine the general health of the patient. This would comprise 
severe injuries, mental disturbances, albuminuria, eclampsia, 
chorea, hemorrhages, septic infection, pronounced anaemia, and 
painful or prolonged labors. Heredity seems to play an im- 
portant part in the causation of this condition, and illegitimacy 
often exerts a sufficient effect on the mother to account for the 
insanity of pregnancy or of the puerperium among unmarried 
women. 

These cases are seldom fatal except through personal injury 
inflicted by the patient herself, but quite a number die eventually 
of exhaustion, and others become chronically and hopelessly in- 
sane. Unless the patient recovers entirely within a year it is 
almost certain that she will remain permanently demented, but 
the majority of cases do not last more than a few weeks or a 
month. 

There is a sudden transitory mania which sometimes occurs 
during labor, but it is probably an hysterical manifestation due 
to the severity of the pain, and disappears within a few minutes. 



PUERPERAL INSANITY. 289 

The treatment of these cases lies entirely with the physician, 
and consists chiefly in building up the shattered constitution 
with nourishing and easily digested food, fresh air, good hygienic 
surroundings, and careful nursing and attendance. 

The maniacal cases should be placed in an asylum, unless 
the circumstances warrant the employment of a sufficient num- 
ber of nurses for both day and night duty to keep the patient 
under constant surveillance, and even in the melancholic cases 
the suicidal and homicidal tendencies must be kept in mind at 
all times. 



XXI 

The Care of the Normal Infant 

As soon as the mother has been given the attention neces- 
sary to secure cleanliness and comfort, the nurse may, after as- 
suring herself that she is in good condition, direct her attention 
to the infant. 

The infant was wrapped in a sterile towel, to protect the 
umbilicus from infection, and a warm flannel blanket, and laid 
in a safe place at the time of its birth, and has been examined 
occasionally by the nurse to see that its breathing is satisfactory 
and that there is no bleeding from the cord. If the room is cold 
or the child is not warm and rosy, it should be surrounded with 
hot-water bottles filled with water no hotter than 120 ° ■ F. and 
covered to prevent the possibility of burning its delicate skin. 
The physician will, when the opportunity offers, inspect the in- 
fant's body carefully for deformity, injury, or abnormality of 
any sort, and, if it is perfectly developed, inform the mother of 
its satisfactory condition. If deformity or injury is found, it 
is best to keep the knowledge from the mother for as long a 
period as possible by giving more or less non-committal replies to 
her interrogations, but as soon as she begins to suspect in the 
slightest degree that she is being deceived as to the child's con- 
dition the doctor must be notified. The obstetrician will direct 
the nurse as he sees fit. Usually the father will be told at once 
and the mother informed by him or the doctor. The nurse 
rarely has this painful duty to meet. 

The baby's eyes first receive attention. 

The doctor usually gives this by washing the eyes from the 
inner angle toward the outer with a boric acid solution. He will 
take every care to prevent any contamination of the eye from 
foreign matter and when they have been thoroughly cleansed he 
will open them and use Crede's treatment or some similar 
290 



OILING AND DRESSING THE NEW-BORN INFANT. 



291 




Fig- 137. — Oiling and dressing the new-born infant. All articles are within reach. The 
table is warmed with hot-water bottles. 



2 () 2 \ NURSE'S HANDBOOK OF OBSTETRICS. 

method. If nitrate of silver solution, i or 2 per cent, is used, 
one drop in each eye, he may neutralize this with normal salt 
solution or a 2 per cent, boric acid solution. He may prefer 
argyrdl, 25 per cent., or protargol, 15 per cent. Occasionally he 
leaves this to the nurse. She must take especial precautions 
against allowing vernix or blood to get into the eyes, and against 
any silver solution dropping upon the face. 

The infant must have warmth and protection from strong 
light and draughts. 

The nurse will soon find time to anoint the baby carefully 
with warm sweet oil or albolene, and to remove the vernix caseosa 
which covers the body. 

The oil is poured into a glass or cup, which is placed in a 
vessel and allowed to stand until it is thoroughly warm. The 
nurse will have a small table prepared to receive the infant and 
will never be guilty of placing it upon her lap when this can pos- 
sibly be avoided. No lap can properly support an infant when 
the person is continuously reaching for required articles and 
altering the position of her knees. It is entirely unnecessary and 
nurses should begin to grasp the fact that this ancient custom 
leaves very much to be desired in the way of comfort and effi- 
ciency to .both nurse and infant. 

The method has nothing to recommend it save custom. The 
infant should be handled as little as possible. This can best be 
done by always placing it upon a table. Care can be given more 
expeditiously and efficiently in this way. In a hospital the op- 
portunity for infection through bathing a number of infants upon 
the nurse's lap is obvious. 

Some hospitals have instituted a system of spraying the in- 
fant upon a slab to avoid this source of very real danger. The 
general objections to the lap method occur to the mind at once. 

Any table covered with a blanket and a towel will suffice 
for the first anointing of the baby. Secure warmth beneath by a 
hot-water bottle, and, turning the infant upon its face, apply 
albolene gently but rapidly with a cotton sponge, going care- 
fully in all creases at knee, buttocks, neck and back of the ears 
where the vernix is most abundant. 



DRESSING THE CORD. 293 

Take care that nothing comes in contact with the cord and 
that no oil enters the eye. The head usually requires a thorough 
anointing. 

Dry with a warmed soft towel. The infant is then turned 
over, and the anterior portion of the body anointed in the same 
manner, particular attention being given to the armpits and 
creases in the elbows, groin, and under the chin. Dry thoroughly. 

Doctors rarely dress the cord, but a nurse will be wise if 
she asks for orders as to method before assuming responsibility. 
It should be done with especial care and especially clean hands 
to avoid infection. The cord and surrounding area may be 
washed thoroughly, particularly the point of insertion, with 95 
per cent, alcohol, and a wet gauze dressing of 95 per cent, alcohol 
applied, or it may be cleansed thoroughly with 95 per cent, al- 
cohol and a dry sterile gauze dressing applied. Never use 
powder. It is not sufficiently antiseptic, and it forms crusts 
This dressing can best be done by using forceps to handle the 
dressings. 

The dressing is the usual one in shape. A pad of gauze or 
cotton is cut with a hole in the centre through which the stump 
protrudes. The corners are folded over the stump, allowing it 
to take the direction of least resistance. Over this is placed a 
sterile gauze sponge and then the binder is applied. After the 
temperature is taken and diaper applied, the baby should be 
dressed rapidly and put in a warm crib. 

Children should not receive a tub bath until the cord has be- 
come detached. The cord dressing is not to be disturbed unless 
it becomes soiled, when the same surgical care is to be shown in 
its renewal. 

Unless the dressing becomes soiled with urine or otherwise, 
it may be allowed to come off with the cord some time between 
the fifth and eighth day. If it is necessary to remove it, only 
such of the cotton as can easily be freed from the cord need be 
taken away and the fresh dressing applied exactly as in the 
first instance. The little tags and fibres of cotton that adhere to 
the cord will be sufficiently sterilized by the application of 
the fresh alcohol. 




294 



A NURSE'S HANDBOOK OF OBSTETRICS. 



The Umbilical Cord. — This usually becomes detached from 
the body between the fifth and eighth day after birth, but its de- 
tachment may be delayed until the tenth, twelfth, or even the 
fourteenth day without causing any harm unless signs of inflam- 
mation appear. The nurse will usually find the cord in the um- 
bilical dressing when she removes the binder to bathe the infant, 
and there may be a slight stain of blood. If the bleeding con- 
tinues, as it may in very rare instances, the physician should be 
notified. In most cases the navel will be depressed somewhat 
and absolutely free from any evidence of inflammation. No 
further treatment is required except to keep the part clean and 
dry. 




Fig. 138. — Method of dressing the umbilical cord. 

The clinical record of a normal infant should show a varia- 
tion in pulse of from no to 150. Only experience can teach a 
nurse to accurately count an infant's pulse-rate. Touching its 
wrist will generally startle and noticeably accelerate its heart 
beat. It can always be felt at the temporal artery to best ad- 
vantage, particularly when sleeping. The temperature may 
vary a whole degree, from 98 to 99 F. A feeble infant will 
have a temperature below this, from 97 to 98 . 

Sleep. — The newly born infant requires a great deal of 
sleep and is to be kept in its crib except when it is removed for 
some special purpose, such as nursing or bathing. The infant 
will, during the first few weeks of its life, sleep practically all 



SLEEP. 295 

the time, but it must be expected to cry vigorously for at least 
half an hour each day in order to expand its lungs and develop 
the muscles of its chest and abdomen. It should be laid down at 
once so that it may go to sleep and digest its food properly, and 
if it cries and examination shows that it is perfectly dry and 
comfortable, it should be left alone to stop of its own accord, and 
must never be patted, rocked, or walked about. If at all possible 
the child should be kept in a room away from the mother until 
after the puerperium, in order that this process of disciplining 
may not disturb her. 

Systematic training of this kind during the first few weeks 
of the puerperium, coupled with a regular hour for undressing 
the baby and putting it to bed in a dark room for the night, will 
teach any child to go to sleep the moment it is laid in bed and the 
habit will cling to it as long as the rule is enforced. 

If the plan is to be successful, it must be adhered to ab- 
solutely, and friends and relatives must understand clearly that 
they cannot see the baby under any circumstances after five 
o'clock. 

There is not a healthy child living who has to be rocked or 
otherwise cajoled to sleep whose parents or nurses are not di- 
rectly responsible for the whole matter, and while it may be very 
entertaining to ignore the welfare of the infant entirely and make 
a toy of it at first, the constant care and attention become most 
trying as the years go by, and especially so if other children are 
born and a similar program is followed. A child can be made 
a comfort just as easily as a trial and a burden ; and people whose 
children are up at all hours of the night, have to be rocked to 
sleep and stayed with for hours each evening, and protected 
from bogie men and other terrors of the nursery, have absolutely 
no one to blame but themselves. 

In these matters of discipline the nurse can only advise the 
parents as to the best course to pursue for their own personal 
comfort and the good of the child, but if they prefer to make 
themselves and every one about them miserable for a number of 
years rather than forego an ill-timed frolic with the baby, they 
cannot be denied the pleasure of doing so. 



296 A NURSE'S HANDBOOK OF OBSTETRICS. 

Infant's Cries. — After the child is born and has cried lust- 
ily, it becomes quiet and at once sleeps. After the eyes, navel and 
skin have received the necessary care it is dressed and placed 
in a warm crib, and it will not cry unless it is wet, hungry, or 
ill. A nurse should learn to distinguish an infant's condition 
and needs from the character of its cry, which all nurse's text- 
books describe — a loud insistent cry with drawing up and kick- 
ing of the leg, denoting colic, either intestinal or due to the pass- 
age of red uric acid deposit from the bladder. Sometimes this 
point may be decided by finding this red stain upon the diaper. 
A fretful cry if due to indigestion will be accompanied by green 
stools and passing of gas. A child's whining cry is noticeable 
when the infant is ill, premature or very frail. A fretful, hungry 
cry, with fingers in mouth, is easily known. 

A peculiar sharp, sounding cry is emitted where there has 
been any injury suggesting a cerebral condition. A nurse should 
make every effort to recognize any deviation from the usual 
manner in which an infant announces his normal requirements. 

Adherent Foreskin. — In a male child adhesions between 
the prepuce and the glans penis are very common. The fore- 
skin may be extended beyond the glans. A very small opening 
is spoken of as a phimosis. A curdy secretion, called smegma, 
may form in considerable amount and collect under the prepuce 
behind the glans ; small amounts of urine may also be retained 
and all of these conditions favor irritation. The doctor will 
perform the delicate operation of separating the adhesions. A 
nurse must never attempt it. It should be left alone and in no 
way manipulated by unskilled hands, or a serious condition known 
as paraphimosis may result. 

The doctor will sometimes expect the nurse to do the daily 
dressing, following a dilatation and retraction and will direct 
her. The manipulation will be difficult at first and must be done 
quickly. But the use of the probe is rarely expected of a nurse, 
a cotton sponge, the gentlest pressure with sterile vaseline for 
the lubricant generally serving the purpose. Soapy water should 
never be used to bathe this denuded tissue. Use sterile warm 
salt solution. Similar adhesions are often found about the 



WEIGHT. 



297 



clitoris in female infants, but then destruction is not so easily 
accomplished and should be left entirely to the physician. Oc- 
casionally a slight bloody discharge may come from the vagina. 
It may be due to injury or is apparently menstrual in character. 
It rarely reappears and needs only cleanliness for treatment. 

Chafing, Scalding or Eczema Intertrigo. — This is due 
to moisture and the irritation of adjacent surfaces. In the female 
infant there is not infrequently a vaginitis with the usual swell- 
ing and purulent discharge. Practically all genital infection is 
the result of neglect and careless handling. It may be brought 
to the area by the nurse in the same manner she may infect the 
mother. It may be due to contaminated lochia or pus ; neglect 
for a few hours is enough to start up irritation. All irritation 
of the genitalia must be treated with absolute cleanliness and 
the parts must be kept dry. This applies to all conditions not 
due to specific constitutional infections. Soap and water are 
to be discontinued at once, and the infant should be patted clean 
with olive oil and dusted with stearate of zinc or talcum powder, 
as commercial toilet powders nearly all contain boric acid powder 
which burns and irritates. Removal of the cause by eliminating 
pressure, with rest, cleanliness, and preventing moisture of the 
tissues, will usually check the inflammation. No properly quali- 
fied nurse will permit such a condition to arise in a child under 
her care. Properly fashioned, washed and ironed diapers used 
only once will be a large factor in preventing its occurrence. 

Weight. — The normal weight of a male child at birth is 
seven pounds and eight ounces, while that of a female infant is 
six pounds and eight ounces, or one pound less. These are the 
usual, average weights of normal infants, and two-pound mites 
or twelve-pound boys are as rare as Siamese twins, despite the 
marvelous tales of proud parents and ignorant midwives. 

During the first few days of life the infant normally loses 
in weight, until about the sixth or seventh day, it has dropped ten 
ounces below its birth-weight. This is because its digestive ap- 
paratus is barely learning to functionate at this time and the child 
assimilates little if any of the very small quantities of material 
which enter its stomach. For nearly a week it lives almost en- 



298 \ NURSE'S HANDBOOK OF OBSTETRICS. 

tirely on its own subcutaneous fat and gives off in meconium, 
urine, perspiration, and otherwise far more matter than it takes 
in by mouth. About the time that the meconium begins to disap- 
pear from the stools the weight commences to increase and, in 
normal cases, does so regularly until, by the tenth day of life, it 
equals the birth-weight ; after which, if all goes well, it continues 
to increase until, at six months, it is double the birth-weight. 

For example, a child which weighs seven pounds and eight 
ounces at birth should be expected to drop to six pounds and 
fourteen ounces by the fifth or sixth day, increase to its original 
weight of seven pounds and eight ounces by the tenth day, and 
weigh fifteen pounds when it is six months old. Any marked 
deviation from this course should be reported to the physician. 

Directions for nursing are given and it must not be for- 
gotten that the baby requires a drink of tepid boiled water 
several times daily. This amount should be increased if a red 
deposit is found upon the diaper, following an attack of crying. 
The nurse must know with certainty whether the infant has 
urinated. If no urination occurs during the first twenty-four 
hours (an unusual condition) a cause must be looked for and 
an obstruction will probably be found. A prompt report should 
be made of the condition. 

The sterile water should never be given with a medicine 
dropper. The danger of injury to the mouth through careless 
administration is great. A small boiled bottle and nipple are 
better for the purpose. 

The needs of the baby and the ideal nursery will be included 
in the next chapter. 



XXII 

The Ideal Nursery and Layette 

THE IDEAL NURSERY 

As a guide to the nurse in answering the many questions an 
inexperienced mother will put concerning the infant's wardrobe, 
nursery and accessories, this chapter is added. 

The change from the old to the new order as applied to the 
hygiene of the baby is nowhere else shown to be so great. 

For the nursery, which is to be a home for a child, theoreti- 
cally the only logical reason for the maintenance of a home 
itself, a room flooded with sunshine and properly ventilated is 
the best. The proper sort of nursery should be secured if it is 
at all possible. Families might change a cramped dark apart- 
ment for a more desirable residence if the baby was considered 
as he deserves. Necessities for the child's health, comfort and 
freedom, as well as his protection from infections and accidents, 
can all be secured by the exercise of intelligent common sense, 
ordinary foresight, and economy as well. 

Quiet, sunshine, simplicity, warmth and ventilation are es- 
sentials for the baby. A neutral washable brown or green paint 
upon the walls and window shades of tan or dark green are 
suitable. Window hangings may be dispensed with. Eye hy- 
giene must be carefully observed and the infant never be ex- 
posed to a light shining into his eyes. The room should be kept 
quiet and freshly aired at all times. 

Usually the heating system must be accepted and will need 
watchful control. The nursery temperature should be about 66° 
to 70 ° F. during the day and 6o° by night, and if the child con- 
tinues strong a much lower temperature can be safely borne by 
night. The chief point to remember is to afford the necessary 
protection of the child's body from the cold air. This is ab- 
solutely essential and can be accomplished by the use of proper 
sleeping apparel and a proper method of crib making, using 

299 



3oo 



A NURSE'S HANDBOOK OF OBSTETRICS. 



coverings (such as wool or down) that give warmth with the 
least weight. The hlankets should immediately cover the infant. 
Gas and oil heaters exhaust air rapidly, and if it is necessary to 
use them, they must be carefully watched, and the moisture in the 
atmosphere supplied, in a measure, by a large vessel containing 
water, always on the stove. 

The floor should be bare, with washable rugs or covered 



Fig. 139. — Infant's crib with adjustable sides. 

with linoleum. The bed is sometimes a clothes-hamper set upon 
two chairs, but should be a child's metal crib. This should have 
a hair mattress. Where this is not possible, many substitutes can 
be found. Mattress padding, four thicknesses deep, table felt- 
ing or a straw or southern moss may be used and covered with 
a quilted pad. Care and cleanliness by frequent washings and 
airing are essential and a rubber sheet is always necessary for 



PREPARATIONS FOR THE BATH. 



301 



protection if the mattress is to continue in use. The infant must 
never lie directly upon a rubber sheet, but always upon a dry 
pad. Babies require no pillows, breathing more easily lying upon 
the abdomen. When the infant is older a flat hair pillow may be 
used. Down is too heating for use at any time. 

In addition, the furniture, which should all be plain and 
washable, consists of : 

I. A table fenced on all sides and divided through the centre. 




Fig. 140. — Practical infant's crib. It may be raised and swung over bed of mother if 

desired. 

This is to be covered with rubber sheeting or oil-cloth, then a 
pad, and finally a towel or soft blanket for one half, two thick- 
nesses of padding for the dressing half. The infant is to be 
bathed on one compartment and dried. Then laid upon the other 
compartment for its careful toilet. This nursery furniture is a 
stock article abroad, but the fashion persists very strongly here of 
bathing, dressing and handling the infant upon the mother's 
knees. This is very undesirable. It is awkward for the mother, 
however low her chair and table of supplies. It results in much 



302 



A NURSE'S HANDBOOK OF OBSTETRICS. 



unnecessary handling of the infant, much more time is consumed 
than need be, and unless every detail of the bath and toilet has 




Fig. 141. — Double wash-basin. 

been remembered, it means the placing of the infant in some 
convenient spot until the mother returns with the forgotten 
article, pins, hot water, etc. 

When the baby is to be tubbed, the process of undressing, 
washing the head, nose, and ears, soaping Ihe body, can all be 



1 m 



Fig. 142. 



-Paper bags pinned together. One for soiled clothing to be 
for articles to be destroyed. 



•ashed ; the other 



very expeditiously accomplished upon such a table and, with the 
tub beside it, all stooping is avoided. The dressing proceeds 
rapidly on the dry end of the table. Any small table 28 inches 
high may be so divided and fenced for protection. 



PREPARATIONS FOR THE BATH. 



303 



2. An infant's dressing screen is now on the market which 
does away with the insanitary exposure of the most personal 
toilet articles of the infant. This screen, which closes upon 
itself, has shelves, drawers, towel rack, and may be exceedingly 
elaborate with glass shelves, covering tufted satin, or plain wood. 
It may be made with a wooden frame and backed with linoleum 
or any washable material or most daintily fashioned. Every 
article belonging to the baby should find its place inside this 
screen, instead of the discredited baby basket which is invariably 
dirty. The soap should always be in a shaker, as are some 
shaving soaps. Nothing that the baby uses is quite so dirty 
as the usual cake of castile soap. Sea sponges, long discarded 




Fig. 143 A. — Infant's dressing screen. Holds all required articles and protects table. 

Fig. 143 B. — Infant's dressing table. One half for bath and change; one half for use after 

infant has been bathed and dried. 

in surgery, are equally insanitary for the use of the baby. Clean 
rags boiled often are far better. Cotton sponges in one piece may 
be shaped to cleanse the ears and nose. Never use cotton upon 
a tooth pick to cleanse nostrils. The danger of detachment is 
a real one and ears may be seriously injured by the manipulation 
of such an applicator. 



3^4 



A NURSE'S HANDBOOK OF OBSTETRICS. 



The shelves will hold the double basin, two pitchers, hot- 
water bottle and all toilet accessories. This screen opens, is 
light and on rollers, and is to be placed around the nursery table. 
This avoids a draught and places within immediate reach all the 
articles which are required. 

3. A chair without arms for the mother or nurse. 

4. A metal bed for the nurse. 

5. An infant's wardrobe or chiffonniere. 

0. A table to hold scales and any other article. 

7. A low table or flat chair to hold the bath-tub. 

8. An armless rocker for visitors. 

9. Infant's bath-tub. 

These articles may be as exquisitely dainty or severely plain as 
the mother may wish. But the infant thrives best where it has 
quiet, sunshine, cleanliness, and an equable temperature. 

If the nursery has an adjoining bath-room as well as a 
screened porch many steps may be saved. A board over one 
end of the bath-tub may serve instead of the nursery table. It 
is low, however, and inconvenient because of the number of 
times in the day the infant requires attention and appropriates 
the bath-room. 

Much has been written to popularize the long-recognized 
scientific fact that clothing and environment produce definite 
effects upon the baby's physical and mental development. Pins, 
tight bands, rough seams, weighty clothing, scratchy laces, insuffi- 
cient diapers, noise, unnecessary handling, bootees and a host of 
other sufferings to which the infant has long been subjected have 
now a great light thrown upon them, and mothers are asked, on 
all sides, to consider these matters and to remedy the defects. 

The National Children's Bureau of the U. S. Department of 
Labor has published two monographs on Pre-natal Care and 
Care of the Infant which are very valuable. Mothers are ad- 
vised to secure them. 

The diaper is quickest made in the old way. twice as long 
as broad, in two sizes 20 X 40 inches and 26 X 52 inches. The 
first used should be still smaller, 36 inches square and folded 
four deep. 



PREPARATIONS FOR THE BATH. 



305 



Pins are required to adjust these diapers. They reach too 
high up the back and should be replaced by the shaped dia- 
per now so strongly recom- 
mended. The pattern is 
shown and explains itself. 
It is time the diaper pin dis- 
appeared from use. It has 
nothing in its favor except 
undisputed sway. Tapes 
that do not twist and straps 
not easily torn consume no 
more time in adjusting than 
does the finding, opening 
and applying the pins. The 
diaper is more comfortable 
when shaped, it allows 
more freedom to the limb, 
and, if properly fitted, it af- 
fords equal protection. An 
inside absorbent pad must al- 
ways be used, for the econ- 
omy is obvious. An oblong 
or towel-shaped diaper is 
excellent for larger chil- 
dren. The diaper is folded 
down from the top to 
double the thickness under 
the seat and the long end 
drawn up between the legs 
and fastened in four places. 
The tapes are to supersede 
the safety-pins where these 
are used. The fairly com- 
mon accident of swallowing safety-pins would be rare if the 
infant's clothing could be fashioned to dispense with their 
use. Being " stuck " with the point of a pin is only one of the 
possible discomforts to which the infant is subjected. There is 
20 




Fig. 144. — Method to secure air for infant in 
a city apartment. 



306 



A NURSE'S HANDBOOK OF OBSTETRICS. 



at all times more or less pressure of the small body upon them. 
Again, the large ill-fitting diaper between the thighs may result 
in a slight deformity to the femurs, and the delicate genitalia may 
be injured by the same pressure. 

The infant's temperature should be taken by rectum, and 
with proper training the bowels may be evacuated before the 
morning bath is begun. It is to be given according to a schedule. 
All necessary articles are to be within reach. The temperature 




Fig. 145. — Another view of Fig. 144. 

of the room should be about 70°to 75 ° F. All draughts are to 
be excluded and entrance to or egress from the room is not to be 
permitted unless the same temperature is maintained outside. 

The tub may be enamel, which is expensive but indestruct- 
ible ; a rubber tub, which it is impossible to scrub quite clean ; a 
papier mache or a tin tub. These last are usually painted and 
will serve very well for at least one year. 

The temperature of the bath may vary somewhat accord- 



INFANT'S CLOTHING. 



307 



/ 




Fig. 146. — Diaper shaped according to pattern. No pins required. 



308 A NURSE'S HANDBOOK OF OBSTETRICS. 

ing to the age and strength of the infant, but it must never be 
cold enough to cause shivering or blueness of the extremities, 
and must invariably be gauged by the thermometer and not 
"guessed at " by the nurse. In a general way the following 
table, given by Rotch, will meet the requirements of most infants, 
but the effect on the child must be watched carefully and the 
temperature raised if necessary. 

TEMPERATURE OF THE BATH FOR DIFFERENT AGES 

Age Temperature 

At birth 98 F. 

During the first three or four weeks 95 F. 

One to six months 93 F. 

From six to twelve months 90 F. 

Twelve to twenty-four months 86° F. 

Then gradually reduce in summer to 8o° F. 

In third or fourth year, if possible, reduce to 75° F. 

The infant is to be laid upon the bath end of the table, its 
clothing removed excepting its band and diaper. A cotton 
sponge should be saturated in a 2 per cent, solution of warm 
boric acid or boiled water, and used for washing the exterior of 
the eye. Care must be taken that no fluid escapes into the eye. 
Washing the healthy eye can do no possible good and may do 
much harm, the solution being often contaminated and old. The 
ears and nostrils are to be washed with small shaped pledgets of 
absorbent cotton. Toothpicks with cotton or sponge attached 
have no place in nursery. There is a great reaction against wash- 
ing the baby's mouth frequently ; all pediatricians seem to agree 
that this has been overdone in the past, and so now the avoidance 
of this source of danger for the introduction of germs and in- 
jury to the very delicate structure of the surface is strongly 
advised. 

Once a day the tongue may be cleansed with a 2 per cent, 
solution of warm boric acid. A piece of cotton should be ap- 
plied, most gently, with a surgically clean little finger. This is 
better than the cotton on a toothpick, so often used as an ap- 
plicator. If food is vomited, curds may be removed in this way. 
Separate pledgets must always be used for the mouth, ear, and 



TEMPERATURE OF THE BATH. 309 

eyes. Paper bags may receive the articles to be destroyed and 
another those for the laundry. The head and the face are to 
be washed. 

The child's body is now to be soaped thoroughly and quickly 
with the sponge and water from the proper side of the double 
basin, and as soon as this is done the infant is lifted carefully 
into the tub and allowed to kick and splash for a few seconds. 
If the cord has not yet separated, the infant is not put into the 
bath. 

Nearly every baby will thoroughly enjoy its daily bath if it 
is begun before the child is old enough to know the meaning of 
fear, but when the tub bath is not commenced until the infant 
is several weeks old, or if it is ever dropped or otherwise fright- 
ened or injured in the bath, it may require great patience and 
perseverance to overcome the little one's terror of the water. 

The nurse must make sure that the water is of the proper 
temperature, and the baby is to be held firmly and dipped in the 
water slowly and carefully so as to avoid any sudden shock. 
When the child is, for any reason, actually afraid of the water, 
a thin towel may be laid across the top of the tub, covering it 
entirely, and the baby held over the towel and then lowered 
very slowly and carefully into the water. A few baths given 
in this way may be successful in reassuring the infant and over- 
coming its fear. 

After a few seconds in the tub the child is returned to the 
table, covered at once with a warm towel, and " spatted " softly 
until it is dry. A small soft towel is then used for drying the 
creases of the body and the armpits, groin, and buttocks, and 
talcum powder is applied lightly to all folds of the skin and 
places where moisture might collect. 

Remember that the baby is to be soaped and washed on the 
table, and not in the tub until it is old enough to sit up ; that 
separate sponges, wash-cloths, and water are to be used for 
the body, buttocks and face. 

The infant, wrapped in the towel, is now laid in the scales 
and the weight carefully noted and recorded on the weight chart 
after the bath. Before recording the weight the towel is to be 



3io 



A XURSE'S HANDBOOK OF OBSTETRICS. 



weighed and its weight deducted from that of the infant and 
towel together. 

If the cord dressing has been removed it is replaced in the 
manner already described and the binder sewed carefully over it 
or tied. The diaper, folded in triangular shape, is laid well up 
under the buttocks and on it is placed a square of folded gauze, 
lintine, or old soft pieces of napkins or table-cloths, which will 
absorb a good part of the urine and take up all the discharges 
from the bowels. These are to be changed and destroyed as 
soon as they become soiled, and their use will effect a great 
saving in washing. The diaper is now tied carefully and fastened 
to the binder in front, and the infant's socks are put on. 

The outer clothing consists of three pieces, — an undershirt 
of stockinet with sleeves, a flannel petticoat without sleeves, and 
a muslin slip. These garments are all made so that they can be 
fitted into each other before the infant is bathed and all slipped 
on at once. They should be drawn up over the feet and never 
put on over the head, for fear of frightening the baby, and after 
the sleeves are adjusted properly the child is turned on its face 
and the three layers of clothing closed in the back. 

It will be seen that this method of dressing the child causes 
no pressure on the chest or elsewhere, and allows perfect free- 
dom of movement to all its muscles. As the infant is turned 
over but once in the entire process of dressing, it is not tired or 
excited as when the old-fashioned style of clothing is used. On 
this account it is not at all fretful, but more or less drowsy, after 
its bath, and quite inclined to nurse and go to sleep at once, to 
the great comfort of every one concerned. 

A folded diaper may be laid loosely under its buttocks, be- 
tween its body and the undershirt, to protect its clothing, and its 
diapers must be changed the instant they are wet or soiled. 

The whole process of bathing, drying, powdering and dress- 
ing the infant must be carried on with the keenest realization of 
the care which the delicate body requires. Roughness insures 
abrasions, and abrasions insure infections. 

The skin becomes dry after the infant is about four days 
old, and about half of them show, during the first fifteen days, 



THE INFANT'S LAYETTE. 311 

a jaundice known as icterus neonatorum. The exact cause is 
not clear. It is no doubt due to a number of causes, but generally 
it disappears and needs no treatment, but it may be due to an in- 
fected navel and it is best that the dressing be carefully inspected 
for the assurance that this source may be eliminated, always re- 
membering that the point of union of the cord with the body is 
the point of possible infection. The gall-duct may be affected or 
there may be a congenital stricture. This demands the immediate 
care of the doctor. 

Carelessness in cleansing the scalp will result in the condition 
known as seborrhcea capitis, which consists of an over-secretion 
of the sebaceous glands, mixed with dirt, forming a yellowish- 
brown, waxy-looking crust on the head. This will never occur 
if the child is properly cared for, and when the condition is en- 
countered the crusts should be gradually softened with warm 
sweet oil and removed as gently as possible, after which, if the 
head is kept clean there will be no return of the trouble. 

The time when the baby can go out of doors depends upon 
the time of year, the weather, and the climate of the place of 
its birth. Babies born in the summer or in a warm climate may 
usually go out on dry, pleasant days when they are four or five 
weeks old, provided they are kept in the sun with their faces 
shielded from the light. Infants born in the winter or in a severe 
climate are better off in the house, even up to the fourth and fifth 
month, but they should receive fresh air once or twice daily by 
being bundled up warmly and carried into a good-sized room with 
open windows, where they may remain for ten or fifteen minutes. 

THE INFANT'S LAYETTE 

Twelve plain slips of nainsook, crepe, dimity or long cloth 
(linen is objectionable) 27 inches from shoulder to hem. 

Six sack gowns, sleeveless, opening in back, folding over at 
bottom; for the first two weeks. Made of part wool flannel 
for winter, lighter weight for summer. Popular in hospitals and 
difficult to improve upon for first clothing. May be utilized later 
as sleeping robes. 

Six part wool flannel petticoats made Gertrude fashion. For 



3 i2 A NURSE'S HANDBOOK OF OBSTETRICS. 

summer wear should have cotton waists. Always close with 
snaps at shoulders. 

Six shirts, loosely woven mesh silk and wool for winter, or 

Six shirts, loosely woven mesh cotton or silk and cotton for 
summer. Unless the infant is quite small, purchase the second 
size. 

Two dozen cheese-cloth diapers. The softest and most ab- 
sorbent for use the first two months. Cut one yard square and 
stitch into one-quarter yard square diaper pads. Use later for 
inside pads. 

Four dozen diapers of cotton birdseye, domett flannel or 
terry cloth, size 20 X 40 inches and 26 X 52 inches. 

These are better when shaped according to pattern and made 
same size. 

Best of all are the soft absorbent knit diapers so widely ad- 
vertised, but they are expensive because of the number required. 
These are more absorbent than any woven goods. But whatever 
is used must first be boiled to become shrunken and absorbent 
and changed as soon as known to be damp. 

Six straight bands, 6 inches wide and 22 inches long. These 
will be used to keep the umbilical dressing in place. If the doctor 
advises the wearing of a band after the first month these will 
be needed : 

Six knit bands fastened with straps. These have shoulder- 
straps and tabs for. attaching to the diaper, and in summer may 
replace the shirt. 

Six knit straight bands fastened with tapes, of silk and wool 
or cotton. 

Six night-dresses of light soft flannel or crepon. Tapes 
applied flat at neck and wrists. Snaps down front and across 
bottom which is closed by being folded forward. Pinning 
blankets imprisons the legs, interferes with activity ; are unneces- 
sary and objectionable. 

Six pairs cotton and wool long stockings, for winter. 

Six pairs cotton socks for summer. 

Avoid all kid shoes or knitted bootees. They are a source of 
irritation. 



THE INFANT'S LAYETTE. 



313 




314 



A NURSE'S HANDBOOK OF OBSTETRICS. 







THE INFANT'S LAYETTE. 



315 



If the child has cold feet apply external heat. When covered 
with clothing the feet should have nothing at all upon them 
unless a soft pair of stockings are worn. 

Six bibs of fine absorbent Turkish towelling. 

A number of jackets are essential. These may be of dif- 
ferent weights. The body is often not protected in proportion 




Fig. 149. — Band and shirt fastened with tapes. Band should be sewed if necessary. Pins 

should not be used. 

to the lower limbs. This must be met by a more or less warm 
jacket of flannel or a knitted sack. 

A number of blankets for baby's use. The best size is a yard 
or yard and a half square. This outfit is enough to start with and 
does not leave the mother swamped with hopelessness upon the 
nurse's departure. The amount could profitably be doubled. 
If laundering can be promptly done four of each article with 
ten slips and four dozen diapers may be made to serve. Out- 
door garments may be secured later. 

All clothing must be changed night and morning. All articles 



3 i6 A NURSE'S HANDBOOK OF OBSTETRICS. 

worn by the baby as well as its bed must be thoroughly aired every 
day. 

The care of the shirts and bands is a part of the nurse's duty, 
and it is essential that she know how to supervise their washing, 
as they are expensive and easily ruined. They should be washed 
in soft water with a wool soap, and are best dried on a stretcher. 

Diapers must be promptly placed in cold water, rinsed, boiled 
and again rinsed. The soap used must have no free alkali and 
must be carefully rinsed out ; chafing and serious irritation may 
result if this is neglected. Xo diaper may ever be used a second 
time. Less expensive outer apparel and an unlimited supply of 
diapers is the part of common-sense. 

The infant's toilet screen will be fitted with: 

Four soft bath towels. 

Two dozen soft wash-cloths of old linen. 

One-half pound of absorbent cotton. 

One soft hair-brush. 

One small nail-scissors. 

One box talcum powder. Use cotton sponge instead of puff. 

One bath thermometer. 

One hot-water bottle. 

One box of castile soap in shaker. 

One tube plain vaseline. 

Six ounces 95 per cent, alcohol. 

Six ounces sterile boric acid solution. 

Six ounces olive oil or benzoinated lard. 

Four dozen paper bags for waste. 

One double basin. 

Two pitchers. 

One cake white castile soap for the shaker. 



XXIII 

The Accidents, Injuries, and Diseases of the New-Born 

The accidents that may occur at or shortly after birth in- 
clude aspJiyxia and hemorrhage from the cord. 

Asphyxia neonatorum (asphyxia of newly born infants) 
may result from injury during manual or instrumental de- 
livery ; from compression or torsion of the umbilical cord, shut- 
ting off the fetal blood-current ; or from protracted labor alone. 
Any one of these conditions should be enough to suggest the 
probability that the child will be born in a state of suspended 
animation, and preparations for its resuscitation should be made, 
if possible, before the termination of the labor, so that there will 
be no delay whatever. It may be asphyxiated with or without 
mucus in its throat. 

The nurse should have ready one large foot tub containing 
hot water (105 F.) and a basin of ice water and a good sized 
piece of ice. These should be placed side by side on chairs or on 
a low table at a distance from the mother's bed, or even in 
another room. In addition there should be a gum elastic catheter, 
No. 8, for withdrawing mucus from the infant's throat, and a 
number of pieces of gauze, about eight inches square, for wiping 
out the mouth or for placing over the face if it is deemed neces- 
sary to blow air directly into the baby's lungs. At least two warm 
soft pieces of flannel blanket are required, as well as hot-water 
bottles and a pitcher of hot water to maintain a temperature of 
io5°-iio° F. for the bath. 

There are two types of asphyxia neonatorum. In one the 
baby's face and even its entire body are of a livid hue, and the 
vessels of the umbilical cord are gorged with blood (asphyxia 
livida) ; in the other the child's face and body are of a death-like 
pallor and the vessels of the cord are empty (asphyxia pallida). 

The livid cases usually recover, for the lividity only indicates 
an early stage of asphyxiation ; but while the pallid infants may 

3i7 



3 i8 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. ISO. — Slapping upon the back to induce respiration after removing mucus and blood 
from the nose and throat. 



ASPHYXIA NEONATORUM. 



319 






Fig. is 1. — Snapping the finger upon the soles of the feet, to stimulate respiration after 
removal of blood and mucus from nose and throat. 



320 A NURSE'S HANDBOOK OF OBSTETRICS. 

occasionally be made to breathe after prolonged efforts, the 
majority of them die at once or after a few days. 

If a child is born in an asphyxiated condition the cord should 
be tied and cut at once, so that there will be no interference with 
the performance of artificial respiration and also to permit the 
adoption of immediate measures towards its resuscitation. 

No time is to be wasted in determining whether it is dead or 
alive. It is always to be assumed that the child is living, for 
often it is over an hour before breathing can be established, and 
cases are on record where success has followed efforts extend- 
ing over the enormous period of seven or eight hours. More- 
over, even if the child is dead, it is a satisfaction and comfort to 
its parents to know that every possible effort was made to save it. 

There are several methods of performing artificial respiration 
on the newly born infant, but a description of one, and its clear 
understanding by the nurse, is all that is necessary in this place. 

The first thing to do is to hold the infant up by its heels, 
slap it sharply on its back and chest, and insert a finger in its 
mouth to the back of its throat and remove any mucus or blood 
that may be there. If the child does not breathe it should be 
laid on its back, its tongue brought forward and the Xo. 8 
catheter inserted and the mucus aspirated. The tube is blown 
clean and again inserted. Respiration may now be excited by a 
brisk rubbing up and down the infant's spine while suspended 
by the feet in the left hand. If this is unsuccessful the child 
should next be dipped up to its neck in the hot water, held there 
for a moment or two, and then transferred to the cold water for 
an instant, or generously sprinkled with ice water upon the 
chest and back (many doctors object to the immersion of the 
infant in ice water as unnecessary), and back to the hot. While 
it is still in the hot water artificial respiration should be practised 
in the following manner. 

The child is held with the right hand of the nurse under its 
shoulders and its neck lying in the cleft between the thumb 
and forefinger, with the head falling loosely backward. The 
left hand of the nurse supports its thighs, and its entire body, 
with the exception of its head, is submerged in the hot water. 



ASPHYXIA NEONATORUM. 



321 




Fig. 152. — Byrd's method of resuscitation. First movement. Expiration. 
21 



322 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 153.— Byrd's method of resuscitation. Second movement. Inspi 



ASPHYXIA NEONATORUM. 



323 



This means, of course, that the nurse's hands are both under 
water. 

Expiration is now affected by doubling up the body of the 
infant until its knees almost, if not quite, touch its chest. It is 
held a moment in this position, and then inspiration is caused 
by separating the hands and bending the body backward as far as 
possible. This process is repeated about twelve times a minute, 
or once in every five seconds, and by placing her ear close to the 
baby's mouth when the movement of expiration is performed, the 
nurse can tell if the manipulation is effective and air is actually 
being forced in and out of the lungs. Every few minutes the child 
is to be plunged into the cold water and returned instantly to the 
hot, in the hope that the shock will stimulate natural respiratory 
movements of the chest, and from time to time a finger is to be 
passed into its mouth to free it from mucus or other obstructing 
substance. It is highly important that the child be kept warm as 
possible. Receive it from the warm bath into a warmed blanket 
and if the artificial respiration practised be Marshall Hall or 
Sylvester method, the extreme need to preserve the body heat is 
apparent. Whiskey may be rubbed along its spine. 

This routine of hot bath, removal of mucus, ice water, tongue 
traction, artificial respiration is to be repeated. 

Asphyxia means really lack of pulse, apncea meaning lack of 
breathing. If the infant's heart action is very feeble or irregular, 
or if no beats at all can be heard by placing the ear in close con- 
tact with the chest wall, a hypodermic injection of whiskey (ten 
minims) should be given, and if no air can be made to enter and 
leave the lungs when the artificial respiration is performed the 
air passages may be expanded by laying a piece of gauze over the 
infant's face and, with the lips in close contact with its mouth, 
blowing a short, sharp blast down its throat. The air must be 
prevented from entering the stomach and bowels by placing 
pressure directly upon it with the hand. The air is expelled from 
the chest by compression and the manoeuvre repeated. Too much 
air must not be thrown into the lungs, as their delicate structure 
may be ruptured. The artificial respiration is to be resumed and 
continued for at least an hour in the manner already described. 



324 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 154. — Artificial respiration. Sylvester's method. First movement. Expiration. 



ASPHYXIA NEONATORUM. 



325 





Fig. 155. — Artificial respiration. Sylvester's method. Second movement. Inspiration 



326 A NURSE'S HANDBOOK OF OBSTETRICS. 

The combination of the Byrd and Sylvester methods of in- 
ducing artificial respiration combined with a hot bath and the 
Laborde method tongue traction, alternated by the insufflation 
of air into the lungs, may be followed by the Schultze swinging 
method ; usually a last resort. This may be repeated a dozen 
times when warmth must again be applied. This is considered a 
most efficient method and it is said that when properly done this 
method will inflate the lungs even if the child be dead. 

If at the end of this time there are still no signs of life, it is 
hardly probable that anything further can be accomplished, but 
it is usually wiser to continue the efforts for a somewhat longer 
period, if for no other reason than to satisfy the family. A 
pulmotor, if available, is sometimes used with success. 

The physician will, of course, attend to this matter of 
resuscitating the infant if the condition of the mother is such 
that he can leave her with safety, but often the task will fall to 
the nurse, and, in some cases, even after the physician has 
officially pronounced the child dead, the family will be grati- 
fied at further efforts to save it, futile though they be. 

Hemorrhage from the cord may be primary, due to the 
slipping or loosening of the ligature, or secondary from the base 
of the cord when it separates from the body. In the first instance 
the bleeding is from the end of the cord and not from its base, 
and can be controlled by the proper application of a fresh liga- 
ture. The secondary hemorrhage, from the base of the cord, 
occurs at about the fifth to the eighth day when separation takes 
place. It is often preceded by a slight jaundice, and is not an 
actual flow of blood but a persistent oozing, which frequently 
resists every form of treatment until the infant dies in a con- 
dition of exsanguination. This variety of hemorrhage is of 
rare occurrence, and may be due to that peculiar condition 
known as the " hemorrhagic diathesis," in which the individual's 
blood shows no disposition to coagulate, and bleeding from any 
denuded surface is persistent and often profuse; or the child 
may be the subject of a syphilitic taint. 

The treatment by the nurse of secondary hemorrhage from 
the cord consists in the application to the bleeding surface of a 



ASPHYXIA NEONATORUM. 327 




Fig. 156. — Sylvester's method combined with tongue traction. 



i 2 8 A NURSE'S HANDBOOK OF OBSTETRICS. 







Pllll V\ 



Fig. 157. — Schultze's swinging method. First movement. Expiration. 



ASPHYXIA NEONATORUM. 329 

piece of cotton saturated with liquor ferri subsulphatis (solution 
of the subsulphate of iron, to be had of any druggist). The 
physician should be notified promptly, and if by the time he 
arrives the use of the styptic has not effectually controlled the 
oozing, he will doubtless pass two long needles at right angles 
to each other through the base of the umbilicus and apply a 
tight "figure-of-eight" ligature (see Fig. 131). The needles 
must be removed at the end of six or eight hours and an anti- 
septic dressing applied. If this form of bleeding is at all severe 
and persistent, recoveries seldom take place and even if the um- 
bilical hemorrhage is controlled, bleeding may appear in the nose, 
mouth, stomach, intestines, or abdominal cavity ; or the infant's 
body may develop purpuric spots at various points. 

The injuries to the new-born infant are those which occur 
during labor, either from pressure or from manual or instru- 
mental assistance to delivery. 

Fracture of a long bone or dislocation of an extremity may 
be the result of a version, or may occur in a breech case with 
the arms extended above the head when they are brought down 
into the vagina. Fracture of the clavicle (" collar bone ") or of 
the jaw, or dislocation of either of these bones, may follow for- 
cible efforts to extract the after-coming head in cases of breech 
presentation. These cases, of course, can only occur when the 
physician is present, and their treatment rests with him entirely. 

Fractures in the new-born infant usually heal rapidly, but 
it is often difficult to Iceep.the parts in good position during repair. 

Dislocation should be reduced at once, or there will be great 
danger of permanent deformity in the joint 

Injuries to the head caused by the forceps usually disappear 
within a few days, even when they are quite marked at first. If 
there is actual laceration of tissue, which will only occur when 
the instrument slips, or if there is a destruction of 'tissue- vitality 
from very prolonged pressure, it is quite probable that perma- 
nent scars will remain. Neither of these injuries will happen 
when the instruments are judiciously used, and any scar that 
may result will be so small and faintly marked by the time the 
child is five or six years old that it will be scarcely noticeable. 



330 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 158. — Schultze's swinging method. Second movement. Inspiration. 



ASPHYXIA NEONATORUM. 



331 




. / i ' : ~ 



•Fig. 159- — Removal of mucus with aspirating cacueter. 



33^ 



A NURSE'S HANDBOOK OF OBSTETRICS. 



Pressure from forceps may seriously affect the brain-tissue, 
causing paralysis of certain groups of muscles (Fig. 161), or 
an acute traumatic meningitis may develop; and the same con- 
ditions may occur when no instruments are used. 

Prolonged pressure on the head during a protracted first 




Fig. 160. — Warm bath combined with tongue traction. 

stage, where the membranes rupture before the os is fully 
dilated, causes a swelling of the scalp at the point where it is 
encircled by the cervix. This is called "caput succedaneum" 
(Fig. 162), and in its milder forms is very common. It is due 



INJURIES TO THE NEW-BORN INFANT. 



333 



to an extravasation of serum into the tissues of the scalp at 
the portion surrounded by the os and free from pressure, and 




V 



Fig. 161. — Facial paralysis of new-born child. (Ahlfeld.) 

it is the more marked the longer the first stage is delayed. The 
portion of scalp rendered cedematous in this manner varies, of 






W 



Fig. 162. — Caput succedaneum. Male, two hours old. (Rotch.) 

course, with the position and presentation, and the condition 
always disappears in a day or two without treatment of any sort, 



334 



A NURSE'S HANDBOOK OF OBSTETRICS. 



Another swelling of the sealp which resembles caput succe- 
daneum in certain respects is caused by an effusion of blood 
between the parietal bone of one side and the overlying scalp. 
This is seldom present when the child is born, and may not be 
noticed for two or three days, when the existence of a swelling 
will be observed, and it will be seen to increase gradually in 
size until about the seventh day after labor, when it remains 
stationary for a time and then slowly disappears. This condi- 
tion is termed "cephalhematoma" (Fig. 163), and usually 




Fig. "163. — Double cephalhematoma. Infant four days old. (Retch.) 



ends in recovery without treatment. It may be due to pres- 
sure in normal labor, or by forceps, but it is also occasionally 
seen in breech cases in which no instruments were used nor pro- 
longed pressure exerted on the after-coming head. These cases 
are not common, and require no further mention. 

The diseases of the new-born infant are ophthalmia, icterus, 
spina bifida, mastitis, vaginal hemorrhage in female infants, 
umbilical hernia, umbilical vegetations, congenital cyanosis, and 
tetanus. 



OPHTHALMIA NEONATORUM. 335 

Ophthalmia neonatorum is a disease of the eyes char- 
acterized by a profuse, purulent discharge due to infection 
generally from the genital canal at the time of birth and 
usually of gonorrhceal origin. This is not always the case, how- 
ever. The lack of proper hygiene by the doctor or nurse or 
mother may carry the germ to the eyes of the infant. From 
25 to 30 per cent, of all children in schools for the blind are the 
result of a gonorrhceal infection. Pus, syphilis, trachoma, acci- 
dents, etc., are the other causes of preventable blindness. 

The disease appears two or three days after birth, provided 
the infection occurred at this time, but as the septic matter may 
be introduced into the eye at a later period by dirty cloths and by 
neglect of the proper care of the child, the onset of the trouble 
may be much later. Both eyes are usually affected, and they 
are first suffused with a watery discharge and somewhat con- 
gested. Within twenty-four hours the lids are very much 
swollen, and a thick, creamy, greenish pus is found under them. 
Later the swelling becomes so marked that the eyes cannot be 
opened, opacities of the cornea occur, the conjunctiva is ulcer- 
ated and then perforated, and the eye collapses and atrophies. 

The treatment consists, first in Crede's method or in the use 
of a 5 per cent, solution of protargol dropped into the eyes im- 
mediately after the labor, and this should always be done as a 
preventive measure. If the disease develops in spite of this 
prophylactic treatment, the infant is to be kept in a dark room 
and the eyes bathed at intervals of from twenty to thirty minutes 
with sterile ice-cold saturated solution of boric acid. Iced cloths 
must be kept constantly on the eyes until the inflammation has 
subsided, and when the boric acid solution is used the lids must 
be separated so that it will flow freely into the eye and reach 
every part of the diseased tissues. 

Whenever the iced cloths are changed or the boric acid is 
used, fresh pieces of gauze must be employed and the old ones 
destroyed at once by burning. If opacities appear on the cornea 
in the form of small milky-white spots, the physician must be 
notified immediately, for, unless the most energetic measures 
are adopted without delay, the sight will be destroyed. 






A NURSE'S HANDBOOK OF OBSTETRICS. 




OPHTHALMIA NEONATORUM. 



337 



The nurse must remember that this is a distinctly infectious 
disease, and that there is extreme danger of conveying it to 
others and of setting up an acute infection in the maternal 
genital tract. Even the eyes of the nurse herself may become 
infected unless she is most painstaking in her methods. Gloves, 
cap, gown, and glasses must be worn by the nurse. The pa- 
tient is placed upon a table and the nurse seated at its head. She 
must handle all dressings with forceps. If one eye only is in- 
fected the sound one must be protected by a Buller shield 
fastened to the face by an adhesive strip, and must be inspected 
at least twice a day for possible infection. 

Every article used by doctor, nurse, and patient must be 
absolutely diverted from use to other purposes. 

The ice-pads should be of soft lintine, quaker flannel or some 
such material and cut into one-inch squares. These should be 
placed upon a cake of ice, and applied (three to the minute) 
upon the eye ; irrigations are done with a medicine dropper or 
syringe from the inner angle of the eye outward. The pus must 
be entirely removed while the eyelids are separated. Pro- 
longed irrigation of large amounts of solution over a surface 
already freed from pus is not so much ordered as formerly. 
The prescribed douches may be of boric acid, or bichloride 
mercury solution i : 10,000, saline or permanganate of potas- 
sium solution ; the temperature should be tested by a ther- 
mometer and must not exceed 75 ° F. Care must be taken not 
to direct the stream from an irrigator directly against the 
child's eye. The child's head must be lowered and the solution 
drain into a kidney basin. If such a solution is used a small 
Kelly pad or an improvised one of stork sheeting or rubber may 
be employed, care being taken not to infect the ear with the 
solution ; but the infant must never be picked up or placed upon 
the lap of the nurse. 

The doctor in charge issues orders as to drops, method of 
irrigation, solution, schedule of ice applications, etc. He may 
vary this treatment with hot applications. These can be ap- 
plied in the same manner, an electric or alcohol stove supply- 
ing heat for the solution. 
22 



338 



A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 165. — Technic of irrigating eye with medicine dropper and permanganate solu- 
tion. The child must be drawn to the head of the table and its body elevated if large 
amounts of solution are used. A small Kelly pad or rubber must be placed under the 
lowered head and empty into a pail. 



OPHTHALMIA NEONATORUM. 



339 



These cases always require two nurses. The feeding, bath- 
ing, proper disinfection of discharges and linen, preparation of 
dressings, treatments, etc., demand the utmost care in technic, 
and the care of the mother becomes a grave matter to prevent 
further infection. 

They require strict isolation, if an epidemic is to be averted, 
in a home, institution, or hospital, and the responsibility for 



1 


ft) 




1) 




o 

n 




4 

iijjiii!!! 
1 4 



Fig. i66. — Thumb forceps. 

spreading infection rests most often with the nurse. The dis- 
ease may last for weeks or may be of a less virulent type. 

Ophthalmia neonatorum is a serious condition which may 
result in total blindness, but if suitable treatment is adopted at 
the very outset of the disease and intelligently carried out the 
sight can usually be saved. The entire treatment is, of course, 
under the direct supervision of the physician, and in severe cases 
he will often deem it best to call an oculist in consultation. 



340 A NURSE'S HANDBOOK OF OBSTETRICS. 

Icterus neonatorum (jaundice of the new-born) is a 
fairly common condition of somewhat uncertain origin, but be- 
lieved by many to be due to infection of the umbilicus. It 
often appears in its milder forms among strong, healthy infants, 
the yellow color of the skin showing first on the second or third 
day and increasing in intensity until the ninth or tenth, when 
it begins to disappear. No treatment is required unless the in- 
fant shows symptoms of severe constitutional disturbance, and 
in the vast majority of cases a favorable outcome may be ex- 
pected. 

Winckei/s Disease. — This is a very rare and fatal septic 




Fig. 167. — Spina bifida of dorsal lumbar region. Infant forty-eight hours old. Died when 
ten days old. (Rotch.) 

disease of new-born infants, marked by icterus, hemorrhage, 
bloody urine and cyanosis with malignant jaundice. The cause 
is not clearly known. The poisons which cause these symptoms 
are said to be connected with the rapid metabolism of labor. 
The symptoms resemble pernicious vomiting or acute atrophy 
of the liver. The intense jaundice is found with hemorrhage 
or fatty degeneration. Among other causes suggested are over- 
doses of chloroform to the mother, and asphyxia, which is 
usually associated with it. The nurse by close observation of 
symptoms may secure immediate orders, and prompt measures 
may possibly prevent the development of this condition. 

Spina bifida (Fig. 167) is due to the congenital absence of 



SPINA BIFIDA. 341 

one or more vertebral arches, usually at the lower part of the 
spine. This allows the membranes covering the spinal cord to 
bulge outward, forming a soft fluctuating tumor filled with 




Fig. 168. — Spina bifida. Spontaneous cure. Male, four and one-half years old. (Rotch. ) 

cerebrospinal fluid. The tumor is diminished by pressure and 
enlarges when the infant cries. The disease is usually fatal, al- 
though a certain few cases have been cured (Fig. 168). The 
most common outcome is ulceration of the sac followed by it's 



342 A NURSE'S HANDBOOK OF OBSTETRICS. 

rupture and the escape of its contents. Convulsions then occur, 
and death follows within a few hours. 

When the tumor is very small and shows no signs of increas- 
ing in size, it may merely be protected from injury and infec- 
tion by carefully applied dressings, but the more severe cases 
are treated surgically if at all. 

Mastitis (inflammation of the breast) is occasionally seen 
in very young infants of either sex. The affected breast be- 
comes swollen, tense, hot, red, and painful, and the disease 
usually appears during the first two or three weeks of life. The 
breast is to be anointed gently with camphorated oil and pro- 
tected from injury by a soft, loose, cotton dressing. In other 
respects it is to be left severely alone, and under no circum- 
stances should it be squeezed, rubbed, or massaged. Nearly 
all cases will recover without any trouble, but if, as may pos- 
sibly happen, an abscess should form, it is to be treated sur- 
gically. 

A vaginal discharge of blood is not an uncommon oc- 
currence among female infants, the flow appearing a few days 
after birth, and usually causing the parents considerable anxiety. 
It is of no consequence whatever, and will disappear of itself in a 
few days without any treatment. 

Umbilical hernia (rupture at the umbilicus) may appear 
during the first few weeks of life, but usually not until a later 
period. The tumor may be made to disappear entirely on pres- 
sure but reappears when the pressure is removed and the child 
cries. 

This is due to a weakness in the navel opening of the ab- 
dominal wall caused by non-union of the recti muscles. The 
condition usually disappears spontaneously, but should the pro- 
trusion of omentum persist a two-inch strip of adhesive plaster 
will close the opening. Hernia buttons act as a wedge and pre- 
vent the reduction of this hernia. A pasteboard circle, one inch 
in diameter, covered with gauze may be placed under the strip, 
over the protrusion. 

Other hernias occasionally are observed. They require pres- 
sure applied and are usually outgrown. 



CONGENITAL CYANOSIS. 



343 



Umbilical vegetations are sometimes seen after the cord 
has separated, in the form of little red friable tubercles varying 
in size from that of a pin-head to that of a large pea. The vege- 
tations bleed readily, and are merely redundant granulations 
and of no special consequence. The physician can usually cure 
them promptly by removal with scissors or cauterization with 
nitrate of silver ("lunar caustic"). 

Constipation should be early recognized. It is not often 
met with. If the bowels have not moved in two days a saline 
enema is usually ordered. The nurse will know if there is a 
malformation, or whether the rectum is impacted. If malforma- 
tion is the cause, the constipation is not relieved by enemata of 
saline two ounces at a time, or an injection of two ounces of 
olive oil. This condition is a very serious matter. Hirsch- 
sprung's disease, an idiopathic dilatation of the colon, may be 
the cause. This condition, as well as the absence of an anus, 
require surgical treatment if the infant's life is to be saved. 
Castor oil or a laxative is usually ordered to clear the intestinal 
tract of the meconium and mucus. This generally solves the 
question of the cause of constipation. Water in sufficient amount 
with proper nursing and an occasional saline enema will soon 
establish a habit movement. Massage must not be given until 
after the cord is lost. The physician gives ample instructions 
concerning the treatment, whatever the cause. 

Congenital cyanosis occurs in those cases known popularly 
as " blue babies," and manifests itself at any time from a few 
hours to a few weeks after birth. The infant's body and, es- 
pecially, its face and extremities acquire a dusky bluish or 
purplish hue, which may be almost imperceptible when the child 
is resting, but which is very marked after exertion of any kind. 

The condition is due to a congenital defect in the circulatory 
apparatus, usually in the heart itself, which interferes with the 
flow of blood through the lungs, and so deprives the infant of 
its proper amount of oxygen. 

Most of the cases die in early infancy, although some may live 
to be ten or twelve years old. 

The only treatment is that directed towards the comfort of 



344 A NURSE'S HANDBOOK OF OBSTETRICS. 

the little sufferer, and consists of inhalations of oxygen to re- 
lieve urgent symptoms, and rest, quiet, good hygienic surround- 
ings, and nourishing food of a simple character. Brandy or 
other stimulant may be given when the dyspnoea is severe, but no 
treatment can have any curative effect, and the disease will al- 
ways prove fatal eventually. 

Atelectasis, often present in premature infants, is due to 
several causes, general feeble defective tissues, particularly 
those of the nerve centres and lungs. It is taught by some that 
the special causes are hepatization, injuries to the brain, and 
pleural effusion. Frequent altering of position, artificial respira- 
tion, shaking, alternate cold and hot baths, holding the nose and 
mouth closed, and oxygen are said to be beneficial. In short, the 




Fig. 169. — Opisthotonos. The characteristic convulsion of tetanus. 

methods used to combat asphyxia are indicated in the treatment 
of atelectasis. The development of its muscles must be a very 
gradual process and every effort made to save the child from all 
forms of strain. To survive, it will need to be under the con- 
stant direction of a physician. 

Tetanus is a very rare disease in this country. It is due to 
the action of a special germ, the Bacillus tetani, which in the 
newly born infant enters the system through the umbilicus. 

The disease begins between the third and tenth day after 
delivery, and the first symptom noticed is a stiffness of the 
muscles of the face and an inability to nurse or swallow. This 
is followed by a contraction of the muscles that control the jaw, 
causing trismus or " lockjaw," and within ten or twelve hours 
the spasm extends to the muscles of the neck and back, caus- 
ing opisthotonos, or a rigid arching backward of the body so that 



DIARRHCEA. 345 

it can rest on the neck and heels with the trunk and limbs above 
the level of the bed (Fig. 169). 

As a rule, death occurs within twenty-four hours, but if the 
child can be made to live for a few days it may possibly recover. 

If an epidemic of tetanus is prevalent in any locality, it is best 
for a prospective mother to go to some other place which is free 
from the disease, for her confinement. 

The treatment rests wholly with the physician, and, as the 
patient is unable to swallow, all drugs must be given hypoder- 
mically. The child must be disturbed as little as possible, for 
any sound or movement aggravates the condition. 

Tetanus antitoxin, if it can be secured, combined with stimu- 
lants and opiates, and chloroform by inhalation when the spasms 
occur, are the only means we have for combating the disease. 

Suffocation. — Nurses will always endeavor to arrange for 
separate sleeping quarters of mother and child. The tempera- 
ture required by the infant is between 65 ° and 70 ° F. The 
mother requires a cooler atmosphere than this and separate 
rooms are most desirable for many reasons. Either by malice 
or accident a very considerable number of infants are overlain. 
In London alone, in 1900, there were 615 such cases. Mothers 
showing mental symptoms must be closely watched and the oc- 
currence is always preventable if the nurse removes the infant 
from the mother's bed after each feeding. 

Diarrhcea. — Normally the new-born infant has perhaps 
two or four stools per day. The colostrum acts as an agent to- 
ward emptying the bowel of meconium. Some physicians as a 
routine order castor oil to hasten this process. Occasionally the 
baby has a movement after each nursing and unless the yellow 
liquid stools become green and there is mucus and a strong odor 
with marked excoriation of the buttocks, it is usually quickly 
controlled when the cause has been found. The fault is most 
often with the feeding. If the infant is not nursed the oppor- 
tunity for infection is of course greater than in the breast-fed 
babies. The doctor usually orders nursing to be discontinued 
for twenty- four hours, and water or barley water is given ; at 
the same time a dose of castor oil with saline enemas or some 



346 A NURSE'S HANDBOOK OF OBSTETRICS. 

similar treatment is ordered. Nurses must strictly observe the 
character of the stools and note the same on the chart. The 
irritated genitalia must be carefully cleansed and kept perfectly 
dry. 

Colic. — -Most infants suffer from colic at times. The par- 
oxysm may be more or less acute. If intestinal, an enema of 
warm salt solution, a warm bath, a hot drink, a hot-water bottle 
to the abdomen, a few drops of some carminative such as 
peppermint or wintergreen, or lying upon its abdomen, will 
generally afford relief to the infant. If the colic is recurrent it 
should be reported. The doctor may order treatment such as 
colon irrigation, massage or lavage with external heat, or medi- 
cines such as castor oil or broken doses of calomel, usually 
V20 or V40 grain doses. By this treatment the cause of the 
indigestion is usually removed unless there is an infection. If 
inflammation is present there will be tenderness of the abdo- 
men upon pressure and green stools with mucus, lumps, froth, 
and a foul odor. 

If the colic is urinary, hemorrhage and nephritis as well as 
colic may be present. It is to be relieved by removing the 
cause. The fever and general auto-intoxication often present 
may cause cerebral disturbance and convulsions. In this case 
prompt action is called for, and the doctor is to be notified at 
the first rise of the child's temperature. 

Nurses frequently overstep proper bounds in their efforts 
to relieve colic. No drugs or teas must be administered by the 
nurse. A colic is always a symptom either of digestive or renal 
disturbance, and whether simple or not, during the first two 
weeks of life, calls for an avoidance of drugs that may dis- 
guise the condition, and the faithful administration of as large a 
quantity of boiled water as the infant will take. If convulsions 
appear, the nurse will observe the first painful twitching of 
muscles of the eyes, face, and body following a general rigidity. 
The doctor must be promptly notified, and the infant should 
receive a warm bath, ice cloths to the head and quiet. The 
temperature of the bath should be ioo° F., and this is gradu- 
ally raised to no° to secure relaxation. A thermometer should 



COLIC. 



347 



be used and extreme excitement avoided. The child should 
not be immersed for a longer period than twenty minutes ; and 
the ice application to the face and head must be continued. Upon 
the doctor's arrival, sedatives or stimulation may be ordered ac- 
cording to his view of the causative agent. In a new-born baby 
this may be tetanus, already referred to, injuries received during 
labor, pneumonia of the new-born, or some other infection. 



XXIV 

The Premature and Feeble Infant 

There are three essential factors in the management of an 
infant that is puny and feeble whether its low vitality is due to 
prematurity or to other causes operating on a full-term child. 
These are : to maintain its body temperature ; to provide nourish- 
ment which it can assimilate readily; and to insure its absolute 
rest and quiet at all times. 

The best indication of an infant's ability to fight its own 
battles after birth is its weight. The mere fact that the child is 
born prematurely is of little consequence when compared with the 
number of pounds that it weighs, and a premature infant of five 
pounds will, in general, require no more care and attention than 
a full-term baby that weighs the same. 

The routine of encasing all feeble, small infants in a cotton 
jacket and the anointing with warm olive oil, seems to be losing 
favor with a large number of obstetricians; it is claimed that 
the body heat is not maintained but the infant on the contrary 
is refrigerated. The newer teaching anoints the infant, if this is 
done at all, with benzoinated lard. Aside from a soft diaper, 
its band, Warren slip and coverings are all wool. The infant 
lies in absorbent cotton or eiderdown, either in a bassinette or 
incubator, depending upon the degree of prematurity, and prac- 
tical possibilities. 

As a safe general rule for guidance it may be said that babies 
weighing between four and a half and five and a half pounds 
are to be kept warm by flannel garments and coverings, in- 
stead of being regularly dressed, while those weighing less than 
four and a half pounds should be placed in the incubator; and 
even larger children whose temperature is subnormal often do 
better if wool clothing and coverings are used. 

As soon as a small, feeble child is born it should be well 

348 



CARE OF PREMATURE INFANT. 



349 



anointed with warm albolene or benzoinated lard, wrapped in 
warm flannel and surrounded with hot-water bottles. The cord 
must be tied with special care, and is to be inspected for bleeding 
at frequent intervals, for there is a well-marked tendency to 
secondary hemorrhage in this class of cases. 

A very warm bed for the infant in the baby basket is pro- 
vided by using soft pillows, and an even, warm surface is secured 
by the use of a number of hot-water bottles. Pure wool cover- 
ings should be obtained if possible, and every effort must be made 
to prevent a drop in the body temperature. This means great care 
at birth and immediately afterward. The shock, lack of fat, lack 
of lung expansion, and radiation all tend to send the body heat 
rapidly to 93 ° F. or even less. This, unless arrested by a warm 
bath, incubator or substitute, will quickly cause death. 

Large maternity hospitals all receive premature infants and 
provide efficient care generally. The infant is transported in an 
incubator ambulance, a small portable contrivance devised by 
Dr. J. B. DeLee. If no incubator station is within one hundred 
miles, arrangements can be made and the child successfully in- 
cubated and nursed at home, especially if mother's milk can be 
procured. 

If the child weighs four and one half pounds, or more, it need 
only be clothed and kept warm in a basket or box as described. 
The temperature is to be maintained about 85 ° F., and ventila- 
tion, moisture and complete freedom from draughts must be 
secured. 

Gas or electricity heated incubators are generally installed in 
the large hospitals. Some stations, however, use no incubators, 
but a specially constructed incubating room where the tempera- 
ture, moisture and ventilation are under perfect control. A small 
room in a private house answering these demands is ideal. In 
its absence, if the baby weighs less than four and a half pounds 
an incubator may be rented or purchased and the child (dressed 
as mentioned above) placed in it at the earliest possible moment. 

The principle of all incubators is the same, the only differ- 
ence being in the construction of the various kinds. It has long 
been known that the air surrounding a premature infant must 



350 A NURSE'S HANDBOOK OF OBSTETRICS. 





|| 




Hi 



Fig. 170. — Electrically heated infant incubator. 



INCUBATOR. 351 

be kept exceptionally warm, and formerly this was accomp- 
lished by heating the room occupied by the child to a stifling 
temperature, to the great discomfort of the nurse or other at- 
tendant. 

Fig. 172 shows an incubator designed in 1880. Warmth may 
be supplied by the use of hot-water bottles, water tank, hot air, 
steam, gas, or electricity. 

The incubator is nothing but a miniature room in which the 
infant can lie, and is so arranged that its temperature can be 
regulated to any desired degree, while the interior can always be 
inspected through a glass in the top. Beyond this ability to con- 
trol the temperature perfectly, the only other essential feature 
of a satisfactory incubator is the apparatus which provides for 
its thorough ventilation. 

The incubator is usually heated by means of hot water, and 
this either circulates through a system of pipes, one portion of 
which is exposed to a gas or alcohol flame, or the hot water is 
placed in tanks or bottles in the lower part of the incubator and 
renewed as often as it cools. In hospitals there may be found 
installed elaborate electrically or gas heated incubators with more 
or less perfect devices for securing a continually changing cir- 
culation with the proper proportions of moisture, heat and fresh 
air ; but in private practice a movable incubator must neces- 
sarily be used, the principle being always the same. 

The child lies on a shelf or platform, padded thickly with 
eiderdown or absorbent cotton, about six inches from the floor 
of the box and directly over the coil of pipe or the cans containing 
the hot water, or a large tank. 

Fresh air enters at the bottom, circulates around the heating 
apparatus, where it is raised to the proper temperature, passes 
over the shelf on which the infant rests, and escapes through a 
ventilator at the top. This ventilator is provided with an ane- 
mometer, or small revolving fan, to show whether or not there 
is a free circulation of air. As the warm air escapes from the 
ventilator at the top of the incubator it will cause the anemometer 
to revolve, and this revolution will be continuous unless the cir- 
culation of air is interfered with or the anemometer is out of 




j 5 2 A NURSE'S HANDBOOK OF OBSTETRICS. 



8 




Fig. 171. — Gas heated infant incubator. 



INCUBATOR. 



353 



order. Consequently it must be most carefully watched, and if 
the motion of the little fan ceases or becomes irregular a prompt 
investigation must be made ; the mechanical device must be kept 
clean and well oiled. 

Another method of keeping track of the circulation of air 
within the incubator depends upon the appearance of the glass 
which covers the top. This should be clean and dry at all times, 
and if it becomes moist and cloudy on the inside it is positive 
proof that the ventilation is not good. 

A wet sponge (which must be kept wet, and its use alter- 
nated with another sponge so that the first one may be steri- 




Fig. 172. — Tarnier's incubator, interior. E, wet sponge; P, partition between lower ana 
upper compartments ; A, tube for escape p f air; T, M, V, Z>, b, as in Fig. 151. 

lized) is to be kept in the incubator to moisten the air, but there 
must be a sufficiently rapid circulation to prevent any of the 
moisture from collecting on the glass 

A thermometer, of sufficient size to be read easily, is to be 
placed by the side of the infant in such a position that it can be 
seen clearly through the glass, and the temperature of the in- 
terior must be kept between 88° and 92 F., and with as little 
variation as possible. It is best to start at 92 , and then reduce 
the temperature very gradually and evenly to 88°, reaching this 

23 



354 A NURSE'S HANDBOOK OF OBSTETRICS. 

point by the end of about a week and holding to it for several 
weeks longer, as the physician may direct. 

The electric and gas heated incubators which are found in 
large hospitals require the same intelligent watchfulness and 
care to avoid chilling or, what is equally fatal, overheating the 
infant. 

Sudden changes in temperature must be avoided absolutely, 
and thermometer and anemometer be watched constantly, 
whether the heat control is automatic or not. 

As the cry of a premature infant is very feeble at best, it is 
often quite inaudible when the child is shut up in an incubator, 
and the closest attention must be paid to the condition of the 
baby at all times. 

Many persons are of the impression that once the child is 
placed in a good incubator no further special precautions need 
be taken, but this is a most mistaken idea. Premature or under- 
developed infants require the most solicitous care in every way, 
and to merely keep them at a proper temperature will avail noth- 
ing unless the other details of their management are carefully 
carried out. 

Rest is a most important factor in the rearing of such chil- 
dren, and they must be shielded from excitement and every dis- 
turbing influence. Visitors invariably flock to see an unusually 
small child, and an " incubator baby " will be sure to attract a 
crowd of curiosity-seekers as soon as its existence becomes 
known. The nurse must positively refuse to let any one see the 
child except the members of its immediate family, and these 
favored few can only be allowed occasional and very short 
glimpses. 

All manipulations of the baby must be avoided except for 
absolutely necessary purposes, such as changing its clothing, ad- 
ministering nourishment, altering its position, or cleansing its 
body. The child requires an application of albolene or ben- 
zoinated lard as the doctor may order, twice a day. The lard, 
infant, and blanket must be very warm, and all exposure is to be 
avoided. Occasionally a physician will order gentle passive 
movements to improve the circulation of the extremities. 



FOOD FOR THE PREMATURE INFANT. 355 

Light is to be curtailed by placing a shawl or other piece of 
dark cloth over the glass top of the incubator, and loud or sud- 
den noises must be forbidden. 

The skin, in these cases, is extremely delicate and tender, 
and diapers must be changed the instant they become wet or 
soiled. 

The child is not to be bathed except as is necessary for cleanli- 
ness, and when the diapers are changed the buttocks must not be 
washed with soap and water, but wiped carefully with cotton 
dipped in warm oil or albolene and then dried with cotton alone. 
If the child flourishes the doctor may order it taken from the 
incubator by day and returned at night, also an immersion, for a 
moment, in water warmer than its body heat, about 105 F. 

The cotton jacket is to be changed twice daily, care being 
taken that the fresh one is warm and ready for instant use the 
moment the old one is removed, if this treatment has been 
ordered. If the infant is wearing a Warren gown, and flannel 
coverlets are used, they must be changed every twelve hours to 
be properly sunned and aired. 

The weight and temperature of the child are both matters of 
the greatest importance, for, as in the case of any baby, if the 
child loses weight and its temperature goes up, it is an evidence 
that its food is either insufficient or of improper quality. The 
temperature is to be taken in the rectum and recorded on a 
chart every night and morning, and the weight is to be taken 
and carefully recorded once a day, at the time when the infant 
is changed. It is unnecessary to say that any rise in tempera- 
ture or loss of weight must be reported at once to the attend- 
ing physician. 

The best food for a premature baby is mother's milk, not only 
because it is especially adapted by nature to the needs of the 
child, but because it is very desirable to keep up the secretion 
of the mammary glands, so that, when the baby grows older 
and stronger, it can nurse directly from the breast. 

The milk may be expressed from the breast with the hands 
or with a breast-pump, and is to be received into a perfectly 
clean cup and fed at once, before it has had time to cool. 



356 A NURSE'S HANDBOOK OF ORSTETRICS. 

The only breast -pump worth considering is that known as 
the "English breast-pump" (Fig. 173). This must be kept 
scrupulously clean and free from any curds or particles of sour 
milk, and should be boiled each time it is used. The nurse must 
be very gentle in applying the breast-pump to the nipple, or the 
delicate tissues may be injured and much trouble result. After 
the nipple has been thoroughly cleansed, as for a nursing baby, 
the air is to be forced out of the bulb of the breast-pump and the 
bell placed gently but firmly against the breast so that the nipple 
comes exactly in the centre of the opening. The bulb is now al- 
lowed to expand slowly and gradually, and in a moment or two 
the milk will be seen to spurt out in two or three very fine jets. 




Fig. 173. — English breast-pump. 

As soon as the bulb is fully expanded and full of air the pump 
is to be lifted from the breast, the bulb again compressed, and 
the bell again pressed firmly over the nipple as before. If for 
any reason it becomes necessary to remove the pump from the 
breast while it is still exerting suction on the gland, a little com- 
pression of the bulb will restore the pressure within the pump 
and it will come off of itself. Under no circumstances should 
it ever be pulled forcibly from the breast, and the use of the 
breast-pump should never at any time be painful to the mother. 
In some cases it will be found necessary to combine massage of 
the breast with the use of the pump, and if the milk does not 
flow freely when the pump is used the gland should be stroked 
gently and firmly with the finger-tips from the edges towards 



FOOD FOR THE PREMATURE INFANT. 



357 



the nipple. Both breasts should be emptied at each feeding-time 
and the milk poured into a cup which stands in a basin of hot 
water, until enough is collected for one meal. 

It seldom happens that a premature baby is strong enough 
to nurse from a bottle and the milk must be fed with a spoon, 



Fig. 174- — Feeder for premature infant. (Rotch.) 

a medicine dropper, or some other appliance that will do away 
with all effort on the part of the child. 

Dr. Breck has devised a " feeder " for premature infants 
(Fig. 174) consisting of a graduated glass tube with a small rub- 
ber nipple at the smaller end and a rubber finger-cot at the 
larger. The cot serves as an air reservoir, and, when the nipple 



358 A NURSE'S HANDBOOK OF OBSTETRICS. 

is placed in the infant's month, slight intermittent pressure on 
the cot will enahle the child to get the milk without any effort 
whatever beyond that of swallowing. 

To fill the " feeder " the nipple and cot are removed, a cork 
fitted snugly in the smaller end, and the proper quantity of milk 
poured in through the larger opening. The cot is then attached 
to the top, the " feeder " inverted, and after the cork is removed, 
the nipple is slipped over the smaller end. 

The care of the breast-pump and nursing-bottle, or " feeder," 
whichever is used, is of the utmost importance, for, if germs 
of any sort are allowed to collect in them, the milk will be 
contaminated and the life of the infant will be greatly endan- 
gered. The cot and nipple are to be cleansed with soap and 
water inside and out, rinsed thoroughly, and boiled for five 
minutes before each feeding. The bottle, or glass portion of 
the " feeder " or breast-pump, must also be cleansed with the 
greatest care by scrubbing, rinsing, and boiling. 

It is well to have a number of " feeders," bottles, nipples, 
and cots, so that several of each may be boiled at one time 
and kept in sterile jars until they are needed. 

When mother's milk cannot be secured, cow's milk, modi- 
fied in the manner described in Chapter XXV, must be given, 
but no effort must be spared to secure human milk from some 
other source. This is generally possible and only as a last 
resource is artificial food to be considered. The physician 
must always regulate the strength and quantity of the food, for 
the problem of feeding a premature child with artificial nourish- 
ment presents many difficulties, and is too serious a matter for 
the nurse to undertake on her own responsibility. 

In general it may be said that the premature baby is to re- 
ceive food of half the strength and in half the amount, but 
twice as often as would be given to a full-term child. The 
feeding by mouth does not require the infant to be taken from 
the incubator. The babe may not be able to suck or even 
swallow. It may require feeding by a catheter or by drop- 
ping from the nipple of the feeder. Medicine droppers are to 
be avoided. Elaborate tables have been devised to guide in the 




Fig. 175.— Infant premature at thirty weeks. Birth- weight, four and one-quarter 
pounds. Treated in incubator sixty-four days. Age, nine months. Weight, seventeen 
and one-half pounds. (Rotch.) 



FOOD FOR THE PREMATURE INFANT. 359 

amount and times the infant is to be fed. The physician will at 
all times give definite orders, as over-feeding a premature in- 
fant is easily done. On the other hand, starvation is often the 
cause of its death and is evidenced by a steady loss in weight 
and vitality along with increased stupor. 

The feeding in every case must be regulated to meet the 
needs of the particular baby under treatment, but if the manage- 
ment is at all successful at the outset it will not be long before 
milk of the usual strength for a normal infant of corresponding 
age can be given with safety. 

The beginning may be made with one-half to one drachm 
every hour, day and night, the time and amount gradually in- 
creasing. The first few days it may be ordered diluted with 
water. When nursing is begun, persistence is required to induce 
the tiny babe to take the breast. A shield with small nipple may 
be used or the use of a teterelle may be ordered. It must be fed 
boiled water at regular intervals. The infant may be overcome 
by exhaustion or regurgitation. It may require that oxygen be 
given to prevent asphyxiation. It requires ceaseless vigilance on 
the part of a nurse at all times and the history notes must be 
complete. 

The nurse will often be asked if a premature infant will ever 
develop as well and be as strong and sturdy as one born at term. 
If it escapes asphyxia, atelectasis, starvation, pneumonia and 
other infections, and can be made to live and thrive during the 
first few weeks, there is no reason why it should not ultimately 
be as robust and healthy as any other baby. Licetus, Helmholtz, 
Goethe and Kant are said to have been premature infants. 



XXV 

Infant Feeding 

The best food for a baby is that designed for it by nature, — 
breast milk. The best breast milk is that furnished by the 
infant's own mother, and the next best is that from another 
woman acting as a wet-nurse. 

If the child's mother is unable to supply milk of a proper 
quality and in sufficient amount for its needs, and if the services 
of a suitable wet-nurse cannot be secured, the next best food is 
cow's milk, properly modified to meet the requirements of the 
child. 

Whenever the mother is able to do so she should nurse her 
infant as far as she can, and then make up the deficiency with 
modified cow's milk ; for even a limited quantity of breast milk is 
better for the child than none at all, and the effect of nursing not 
only stimulates the breasts to the production of better milk from 
day to day, but greatly aids the process of involution by which 
the uterus and other pelvic organs return to their normal condi- 
tion after labor. 

Breast milk is to be preferred to any modified milk, no 
matter how carefully prepared, for the reason that it is exactly 
what the child requires, while the other is at best only an 
imitation; it is absolutely free from germs, while cow's milk 
always contains a certain number of bacteria; it is delivered to 
the child in proper quantity and at a proper temperature, while 
bottle food may escape through the nipple either too rapidly or 
too slowly, and is often too hot at the beginning of a feeding 
and too cold at the end. Moreover, the bottles and nipples are 
apt to become sour even when the utmost attention is given to 
their care ; the quality of the milk is always liable to vary ; and 
errors not infrequently occur in the preparation of the food. 

Hence we have to consider four distinct methods of feeding, 
named below in the order of their respective values : 
360 



MOTHER'S MILK. 



361 



1. Mother's milk. 

2. Wet-nurse. 

3. Mixed feeding. (Partly breast milk and partly modified 
cow's milk.) 

4. Artificial feeding. (Modified cow's milk exclusively.) 
Mother's Milk. — Before we can expect a mother to furnish 

good milk for her infant we must see to it that her breasts are 
in the best of condition for performing their functions (Fig. 
176). This necessitates the adoption of measures early in preg- 




Fig. 176. — 'Soft, flabby breasts. Not well adapted to nursing. 

nancy that will prepare the mammary glands for the work that 
lies before them. These measures have already been discussed 
in the chapter on the Management of Pregnancy, but will be 
reviewed here briefly. 

The breasts should be bathed night and morning with soap 
and tepid water, to keep the skin in good condition, and rinsed 
after each morning bathing with cool or even cold water, accord- 
ing to its effect on the patient, to stimulate the activity of the 
glands. During the last two months of pregnancy the nipples 
are to be anointed with white vaseline or albolene every night, 
and this is to be washed off carefully in the morning to remove 



362 A NURSE'S HANDBOOK OF OBSTETRICS. 

any crusts of dried colostrum that may have formed. This dry- 
ing of colostrum on the nipples is one of the most potent factors 
in the causation of soreness or tenderness of these organs, and 
the daily application of the vaseline or albolene effectually pre- 
vents the colostrum from " crusting" and so irritating the deli- 
cate tissues of the parts. If the nipples are short or flattened, 
they should be drawn out with the thumb and forefinger every 
night and morning and held in this position for at least five 
minutes. This simple procedure, practised regularly twice daily 
during the last eight or ten weeks of gestation, will often work 
wonders with nipples so small or flat that nursing is, at first, 
apparently out of the question. 

The condition of the woman's general health has much to do 
with her ability to furnish good milk, and it goes without saying 
that corsets or other garments that compress the chest will inter- 
fere seriously with the development of the breasts. 

Assuming that everything is favorable for nursing, the child 
is not to be put to the breast until the mother has had a good 
rest from the effect of her labor, and, if possible, not until after 
she has had a nap of a few hours. Usually the baby can begin its 
nursing about four or five hours after birth, after which it is 
to be put to the breast regularly, every four hours, day and night 
for the first two days. During this time the breast secretes 
nothing but colostrum, a laxative substance containing prac- 
tically no nourishment whatever. If the infant does not seem 
satisfied with this diet of colostrum, the nurse may give it a 
five per cent, solution of milk-sugar made up with boiled water. 
One teaspoonful of sugar to twenty of water makes the solution 
in the required proportion, and it is best given in an ordinary 
two-ounce vial fitted with a small rubber nipple (Fig. 177)- If 
a small enough nipple cannot be obtained, one may be impro- 
vised by taking the rubber cap of a medicine dropper and 
piercing it with a good-sized needle. 

At or about the end of forty-eight hours the true milk begins 
to appear in the breast, and the infant should now be nursed 
every two hours from six a.m. to ten p.m., with one night feed- 
ing at two a.m. This plan gives the mother two uninterrupted 



HOURS FOR NURSING. 363 

periods of four hours each for sleep, and it is to be adhered 
to until the child is six weeks old, after which the intervals 




Fig. 1 7 7.— Two-ounce vial with nipple. For administering nourishment, water, or sugai 
solution to a very young infant. 

between the feedings can be increased gradually until the fourth 
month is reached, when the night feeding can often be omitted 
entirely. 

For convenience of reference the hours for nursing may be 
tabulated as below : 

First two days Every four hours. 

2, 6, 8, 10, 12 A.M. 



Third day to sixth week. 

2, 4, 6, 8, 10 p.m 

Six weeks to ten weeks { 2 -*°> 7 > 9-3o, I2 AM - 

l 2.3o, 5, 7.30, IO P.M. 

Ten weeks to four months f 2.30, 7, 10 a.m. 

C I, 4, 7, IO P.M. 

Four months to nine months { 7 ' IO A - M - 

1 1, 4, 7, 10 P.M. 

Of course, different meal-times might be chosen with the 
same intervals between, but the hours given are those which are 
least likely to interfere with the meals and other affairs of the 



364 A NURSE'S HANDBOOK OF OBSTETRICS. 

household. Nurses, and physicians as well, will find it a great 
convenience to adopt the same feeding hours for all normal 
infants coming under their professional care, for this plan will 
do away entirely with the possibility of any confusion or mis- 
understanding as they go from one family to another. The 
child can easily be " started " at six o'clock every morning for 
the first six weeks, and this will bring the other meal-times right 
for the entire day. Afterwards the mother may be allowed to 
sleep until seven o'clock before the regular daily programme 
is begun. 

Some physicians may vary this routine according to the 
special needs of the infant. The feeding period is lengthened 
to two and a half, three, or even four hours if the child is large 
and steadily gains in weight. At least four ounces per week or 
over is the normal gain. If this gain is not shown by an accurate 
weight chart the food is not sufficient. 

Immediately before and after each nursing the entire breast 
is to be bathed gently with tepid water and a little castile soap, 
and the nipple washed off with alcohol (95 per cent.). The 
utmost gentleness must be exercised in cleansing the infant's 
mouth, for the tissues are extremely delicate, and if any force 
is used abrasions may be caused which may afterwards serve as 
starting-points for infection. For this reason a sterile wipe of 
cotton or linen saturated in a borax solution or plain boiled water 
may be used to remove particles regurgitated upon the gums or 
tongue. The danger from injury is greater than that from 
food ; and the mouth cleansed carefully in the morning needs 
no further swabbing out, except to remove particles of food. 

The effect of the warm water on the breast is to favor the 
flow of the milk in the first instance, and after the nursing is 
over it adds greatly to the comfort of the patient by removing 
any of the secretion that may have trickled down over the skin. 
The alcohol (itself an antiseptic) sterilizes and probably tough- 
ens the nipple, and as it evaporates almost instantly it cannot 
exert any harmful effect on the infant as might be the case 
with ordinary antiseptic solutions made up of more or less 



CARE OF THE BREASTS. 365 

poisonous drugs. The breasts should have an application of 
sterile lanolin at night. Both the alcohol and lanolin are to be 
applied with sterile cotton sponges on applicators. The Cleans- 
ing of the infant's mouth is for the purpose of removing any 
curds or other substances that might, by decomposition, infect 
the nipple or cause trouble to the child. 

When the true milk begins to appear in the breast (about 
the second or third day), the patient is apt to suffer somewhat 
from a. feeling of fulness and tenderness in the distended 
organs. This can be relieved by the application of a well-fitted 
and fairly snug breast-binder, so adjusted that it will raise 
the breasts up on the front of the chest and prevent them from 
hanging down at the sides and " dragging." After the binder 
has been placed in position under the patient's back and is ready 
for pinning, the breast on one side is to be raised up as high as 
possible over the chest wall, a pad of absorbent cotton about the 
size of the hand placed at its outer side, and held in this position 
by the patient herself while the other breast is treated in the 
same way. This will bring. the two breasts close together in 
the median line, with a deep furrow between them, and it is well 
to place a small strip of absorbent cotton in this depression be- 
tween the organs to absorb perspiration and any possible excess 
in the secretion of milk. The milk at this time and for the next 
few days is apt to flow very freely and in much greater amount 
than is needed by the child, and other little pads of absorbent 
cotton should be placed over the nipples to take up the overflow 
and keep the clothing sweet and clean. These pads must be 
changed at very frequent intervals, for if any sour milk is 
allowed to collect it will not only tend to make the nipples sore, 
but it may seriously affect the child as well. The binder is, of 
course, to be unpinned for each nursing and replaced again as 
soon as the child is through and the breasts have been thor- 
oughly cleansed. It can usually be discarded entirely after a few 
days, and it must be remembered that its only purpose is to 
support the breasts, and that if too snugly pinned it will compress 
the organs and interfere with their functions. 

If the child is to nurse properly it must be properly held by 



366 A NURSE'S HANDBOOK OF OBSTETRICS. 

the mother, and while most women seem to know instinctively 
how to support an infant at the breast, many are so awkward 
about it that definite instructions must be given them. First of 
all, the baby must be comfortable, and so placed that it can 
reach the nipple without any effort. Its head and shoulders 
should rest on the arm corresponding to the breast to be nursed, 
and the mother's other arm should reach over the child's body 
so that the hand can support its back. This is much more easily 
managed when the woman is sitting up, but during the early 
days of the puerperium the patient is, of course, on her back in 
bed. At this time a small pillow placed under her elbow is of 
great assistance to her in supporting the weight of the child, and 
when she is able to be up she should use a chair with arms, on 
which she can rest her elbow or upon which a pillow or cushion 
can be placed when the infant is at its meal. Feeding too 
rapidly, too slowly, allowing the infant's position to interfere 
with his breathing are points to be guarded against by the 
mother. 

The child should be made to understand that it is to begin 
nursing as soon as it is put to the breast, and it should con- 
tinue to nurse vigorously, with occasional brief rests for breath- 
ing, until its meal is finished, when it is to be removed at once 
and laid in its bed. A baby that " dawdles " at the breast, or 
one that is fretful and peevish, either is not hungry or there 
is some fault with the milk, the nipples, or with its own ability to 
nurse. In any event, such a child should be taken from its 
mother's arms as soon as a fair trial shows that it is not going 
to nurse properly, for it is the worst possible policy to keep 
a crying child at the breast for a long period when it is obviously 
unwilling or unable to take its nourishment. It should be kept 
away for a full interval, or until another feeding time comes 
round, when it will probably have learned what is expected of it 
and proceed to its duty properly and without delay. 

If, however, it continues to refuse the breast after this has 
been done, the physician should be consulted. He may find that 
the quality or quantity of the milk is at fault, that there is trouble 



VOMITING AND REGURGITATION. 367 

with the nipples, or that the infant itself is ailing in some way. 
Possibly the infant may be found to be suffering from tongue- 
tie, cleft-palate, thrush, or Bednar's aphtha. 

If everything is satisfactory the baby should nurse heartily 
at its regular meal-times, which, of course, grow farther and 
farther apart as the child's age increases. It should be hungry 
as each feeding time comes round, satisfy itself in at least twenty 
minutes, and at the end of the meal fall into a comfortable, 
drowsy condition or even drop off to sleep. 

The infant should be weighed every day and its weight ac- 
curately recorded in pounds and ounces. It will be found that 
during the first few days of its life it will lose weight in every 
case, because its food, being chiefly colostrum, contains very 
little nourishment and it is obliged to live on its own fat. This 
initial loss in weight is always to be expected, and usually 
amounts to about ten ounces, after which the child begins to 
gain, and should be back to its original birth-weight by the 
time it is ten days old. Thus there is a normal initial loss of 
ten ounces in weight, normally regained in ten days' time. From 
this time on the child should gain steadily from day to day, until 
at the age of six months it should weigh twice as much as it 
did at birth. 

Besides gaining regularly in weight and strength, a baby 
should be happy and good-natured when awake, but inclined to 
sleep a good part of the time between nursings. It should be 
hungry at its proper nursing times, but not before, and its diges- 
tion should be perfect, as evidenced by the absence of vomiting 
and the passage of smooth, bright yellow stools entirely free 
from curds or mucus. 

Vomiting must not be confused with " regurgitation," which 
is a purely normal process by which the stomach gets -rid of an 
overload of food. Vomiting is always accompanied by the symp- 
toms of nausea. It may occur at any time, but usually long 
after nursing. The child cries, grows pale, and even blue, about 
the mouth, develops a cold sweat on the forehead, and, with 
more or less effort, expels a quantity of sour, bad-smelling, 



368 A NURSE'S HANDBOOK OF OBSTETRICS. 

curdled milk from the stomach. This process may be repeated 
at frequent intervals, and the child is evidently sick. Regurgi- 
tation occurs immediately after nursing and at no other time. 
The baby is bright and happy, and merely opens his mouth 
and lets the excess of milk run out on his dress. It is, in 
other words, nothing more than an overflow, and, far from 
doing the baby any harm, does him good by relieving his 
distended stomach. The milk is not sour, and the baby is 
obviously perfectly well. 

Occasionally a child appears to be hungry between feeding- 
times, when in reality it is only thirsty, and it should be given 
small sips of tepid boiled water until it has satisfied its thirst. 
There is no danger of giving it too much water, and it should be 
allowed to drink until it stops of its own accord. In this way 
loss of weight may be controlled to a slight degree. 

In no case should the baby be put to the breast more fre- 
quently than at the regular feeding-hours already named, for a 
young infant requires nearly two hours in which to digest its 
food, and if it is nursed too often one meal will be taken into 
the stomach before the preceding one is digested, with the result 
that vomiting and indigestion will occur. As the child grows 
older it takes more milk at a nursing, and a longer period is 
required for the digestion of its food, so that the intervals 
between the nursings are necessarily lengthened. The point is 
to give its feedings far enough apart to allow the stomach a 
short period of rest before each nursing. 

Usually the milk from one breast will be enough for a very 
young infant, in which case alternate breasts should be used 
for each nursing, but as the child grows older it will be neces- 
sary to put it to both breasts at every feeding. There is no 
harm in doing this at any time, provided the milk of one breast 
alone does not seem to be in sufficient quantity to satisfy the 
child. 

The baby should never be played with or disturbed soon 
after a nursing, for such excitement will almost surely inter- 
fere with digestion and cause vomiting and other disorders of a 



INSUFFICIENCY OF MILK. 369 

serious nature. In fact, a child should never be played with at 
all until it is past six months old, but allowed to devote all its 
energies to eating, sleeping, and developing in every way. 

When, after every precaution has been taken to secure proper 
milk for the child, the food is still not digested, the trouble, if 
not with the child itself or with the condition of the nipples, can 
usually be traced to alterations in the quantity or the quality 
of the breast milk. 

If the quantity is at fault, and the baby is not receiving 
enough nourishment (a condition known as agalactia), the fol- 
lowing signs will serve to indicate the nature of the trouble. 

1. The baby will wake before its regular nursing time and 
be obviously hungry. It will cry and fret, refuse water with 
apparent disgust, and, when nursing is permitted, seize the 
nipple ravenously and nurse with great vigor. 

2. It will continue to nurse long after the breast is empty, 
in its effort to secure enough food, and will cling to its mother 
and cry in a fretful way when an attempt is made to remove it 
from her arms. As has been said, a normal child, receiving 
normal milk, should be perfectly satisfied within twenty minutes 
at the most, after which it should drop the nipple of its own 
accord. 

3. The breast itself, when examined just before a nursing 
hour, will not be full of milk as it should be, and on prolonged 
palpation it may be impossible to express any milk at all from 
the nipple. When the meal-time arrives the breasts should, 
under normal conditions, be firm and tense but never painful, 
and very slight pressure should be enough to cause the milk to 
escape in fine jets. 

4. The child's weight will go down and its temperature will 
go up. In the chapter on the Care of the Normal Infant stress 
was laid on the importance of keeping a careful daily record of 
its morning and evening temperature taken in the rectum, for 
the onset of fever, coupled with a loss of weight, is one of the 
most significant indications that the amount of nourishment is 
not sufficient. 

With these four points in mind, the nurse should have no 
24 



370 



A NURSE'S HANDBOOK OF OBSTETRICS. 



difficulty in knowing when the amount of milk secreted is too 
small. 

To increase the milk flow the condition of the mother's 
health should be looked into carefully, and she is to be shielded 
as much as possible from worry, grief, overwork, or other 
causes of low vitality. If coffee is included in her diet, it 
should be stopped entirely, for this beverage has a decided ten- 
dency to diminish milk secretion. She should drink milk, or 
cocoa, in its place, and extra milk should be taken between meals 
and at night before retiring. It must be remembered, however, 
that too much milk is apt to upset the stomach, especially in 
certain individuals, and lime water or vichy should be added to 
each glassful as a preventive against this form of gastric dis- 
turbance. If symptoms of indigestion develop, the milk should 
be stopped at once, and dispensed with until the stomach is 
again in good working order. 

There is great uncertainty regarding the value of any special 
foods to stimulate the milk secretion. Many foods on the 
markets have strong advocates among physicians, but the final 
value to the mother is questionable. If the milk taken cannot be 
properly digested, a starchy diet with large amounts of fluid 
may be given. Beets and all kinds of shell fish, noticeably crabs, 
are said to increase the quantity of milk to a marked degree. 
The tendency at present is to place the strongest hope upon 
stimulations of the body and the gland itself. 

Massage with cool baths and dry rubs, electricity, and breast 
massage may affect the amount secreted. 

Great patience is often required before the mother is re- 
warded. The present-day teaching is so overwhelmingly in favor 
of a woman nursing her infant that the nurse is urged to carry 
out with every faithfulness all orders that will make this possible. 

The infant's chances for life are doubled. The doctor will 
decide if the gland cannot secrete, or is diseased, or if further 
stimulation is unadvisable. 

An excessive flow of milk (or galactorrnoca) is of rare oc- 
currence after lactation is fully established, but when it does 
occur to such an extent that it soils the patient's clothing and 



CHEMISTRY OF MILK. 371 

keeps her in a constantly uncomfortable condition, it may often 
be checked by the administration of one or two cups daily of 
strong black coffee. This may be varied with the usual with- 
drawal of fluid and elimination. If belladonna is applied ex- 
ternally the effect must be closely watched. 

If the quality of milk is at fault the case will probably 
have to be referred to the physician. 

Up to this time no mention has been made of the chemical 
constituents of milk, but unless a nurse has a fair knowledge of 
these matters she cannot understand the subject of infant feed- 
ing in an intelligent way. 

Milk is a natural emulsion, and consists, roughly speaking, of 
13 per cent, of solids and 87 per cent, of water. 

The solid substances are fat, sugar, proteids, and salts, 
and of these it is only necessary to consider the first three, for 
the salts are unimportant in many ways and never vary much. 

The fat of milk is the cream, the sugar is the kind known as 
" lactose/' or " milk-sugar/' and the proteids make up the curd. 

In good specimens of mother's milk there is, approximately, 
four per cent, of fat, seven per cent, of sugar, and two per cent, 
of proteid. It will be seen that this makes up the entire thirteen 
per cent, of solid matter, but, as a matter of fact, the true 
proportions are slightly less than the round numbers given, 
leaving room for a small percentage of salts. 

Normal mother's milk, as it leaves the breast, is a sterile fluid, 
absolutely free from germs, blood-corpuscles, or pus-cells. It 
should have an alkaline, possibly neutral, but never an acid, 
reaction, and its specific gravity should be from 1027 to 1032. 
Colostrum cells should be absent after the twelfth day, and 
the fat cells should be small, numerous, and of uniform size. 

The proteids of milk vary directly with the specific gravity, 
— that is, the higher the specific gravity the higher the proteids, 
and vice versa. If we know the amount of cream in a given 
specimen of milk, it is possible to make a fair estimate of the 
proteids in a very simple way. Professor Holt, of the College 
of Physicians and Surgeons, has devised a little apparatus, con- 
sisting of an hydrometer and jar, for ascertaining the specific 



372 A NURSE'S HANDBOOK OF OBSTETRICS. 

gravity of milk, a pipette, and two long graduated cylinders with 
glass stoppers, for estimating the percentage of fat. 

The milk to be examined is to be taken from the middle of a 
nursing, or, if it is removed from the breast artificially, after 
about half the entire amount has been extracted. 

This milk is put into one of the glass cylinders with the 
pipette and should fill it exactly to the graduation marked O. 
If specimens from both breasts are to be examined at the same 
time, both cylinders are used. The cylinders, properly filled 
and securely corked, are set away in a temperature of 70 ° F. 
and left undisturbed for twenty-four hours, after which time the 
cream line will be distinctly visible and the percentage may be 
read on the scale. But this, is cream and not fat, which is to 
the cream as 3 is to 5. Thus, if a specimen of milk shows seven 
per cent, of cream, we have : Fat : 7 : : 3 : 5, or four and one- 
fifth per cent, of fat. 

The estimation of the proteids is not quite so simple, but 
it is by no means difficult. 

We can determine accurately the amount of fat in a given 
specimen, and fat, being the lightest part of the milk, tends to 
lower the specific gravity; so that the more fat in a specimen 
the lower the specific gravity would naturally be. Proteid, on 
the other hand, is the heaviest part of the milk, and the greater 
the percentage of proteid, the higher will be the specific gravity. 
Hence : 

(a) If both fat and specific gravity are high the proteids 
must also be high, or the amount of fat will bring down the 
specific gravity. 

(b) If the fat is low and specific gravity high, the proteids 
are probably about normal, the high specific gravity being due 
to the small amount of fat in the specimen. 

(c) If the fat is high and the specific gravity low, the pro- 
teids are again probably about normal, the low specific gravity 
being due to the large amount of fat. 

(d) If both fat and specific gravity are low, the proteids must 
also be low, for otherwise the small amount of fat would make 
the specific gravity high. 



VARIATIONS IN QUALITY. 373 

In collecting the milk for examination great care must be 
taken to handle it as little as possible, and the glass cylinders 
for making the cream tests must be scrupulously clean, or the 
milk may sour before the cream has had time to rise. If at 
the end of twenty-four hours the cream line is not sharply 
defined, the specimen may be allowed to stand six hours longer 
before the percentage is recorded. 

Any marked variations in the proportions of fat and proteids, 
and the presence of any foreign substances in the milk, such as 
blood or pus, will cause, in the infant, indigestion of a more 
or less serious degree. The most common form of disturbance 
is that due to an increased percentage of proteids, and is evi- 
denced by constipation and the presence of curds in the stools. 
If the condition is not corrected promptly, serious illness may 
result. When fat is present to an excessive degree the infant 
vomits and has diarrhoea. It is not difficult to keep these two 
sets of symptoms in mind when it is remembered that the pro- 
teids, being the curd of the milk, would, if in excess, naturally 
cause curds in the stools ; and that the fat, being an oil, would, 
if in too great amount, tend to the production of diarrhoea. 

Both fat and proteids are increased by a diet that is largely 
of animal food and diminished by one consisting chiefly of 
vegetables. In cases where the proteids are in too great amount 
it might be possible to remedy the matter by putting the woman 
on a vegetable diet and then, if necessary, making up the de- 
ficiency in fat by giving her cream to drink. 

Fright, worry, pain, or any other nervous shock, increases 
the proteids in the milk, and the patient must be shielded from 
these disturbances as far as possible. 

Menstruation increases the proteids, but the increase depends 
largely upon the amount of pain that the woman suffers at this 
time. Not long ago it was thought best to stop nursing entirely 
if the menstrual function returned during lactation, but it has 
been found wiser to be governed by the amount of suffering that 
the woman undergoes, and not take the child from the breast 
unless the mother's pain is extreme and the infant plainly shows 
the effect of the change in the milk. Ordinarily it is better to 



374 A NURSE'S HANDBOOK OF OBSTETRICS. 

let the baby undertake the extra digestive strain for a few days 
each month than to risk an entire change in diet. 

The presence of blood or pus in the milk is an absolute 
indication for stopping all nursing at the affected breast. This 
condition is usually due to injury or inflammation of the breast, 
and if the milk remains after an apparent cure, the child must not 
lie allowed to nurse until, by microscopic examination, it is known 
that all evidences of suppuration have entirely disappeared. 

Pregnancy, when occurring during lactation, causes a 
marked decrease in the percentage of fat. It is another, and 
the only other, positive indication to stop nursing entirely. The 
milk is not good for the child, and the mother cannot properly 
nourish herself, her baby, and the foetus in utero, while the reflex 
connection between the breasts and the uterus would make 
nursing under such conditions a very probable cause of abortion. 

As has been said, the presence of blood or pus in the milk 
and the occurrence of pregnancy are positive contraindications 
to nursing; and of the other conditions may or may not be, 
according as they can or cannot be corrected by diet or other 
treatment ; and lastly, there are some women whose milk is 
apparently perfect in every respect and yet who cannot nurse 
their children because, from some unknown reason, the milk 
does not and cannot be made to " agree." 

Wet-Nurse. — Theoretically the wet-nurse is the best substi- 
tute for mother's milk, but practically it is usually better to try 
" mixed feeding " or adopt artificial feeding entirely. The wet- 
nurse is not easily secured ; she is expensive, and usually an ex- 
treme care, causing trouble with other servants and making her- 
self generally unpleasant in her assurance that the family will put 
up with anything rather than have the baby's food changed again. 

The majority of wet-nurses are unmarried women secured 
from some public maternity hospital, as women with homes and 
husbands are not apt to neglect their own children in this way, 
and the probable, if not actual, lack of morality in the nurse is 
an added reason for making her an undesirable member of the 
family. Aside from this, however, an unmarried woman usually 
makes the best wet-nurse, not only because she parts with her 



MIXED FEEDING. 375 

own baby with little or no regret, but she has no husband to 
appear at frequent intervals and demand her wages or upset the 
entire household by threatening to take her away. 

In selecting a wet-nurse a woman should be chosen whose 
baby is as nearly as possible of the age of the baby for whom 
her services are required. She should be a woman of neat and 
cleanly habits, and, preferably, one of more or less phlegmatic 
disposition, and both she and her child should be examined by 
the physician for evidences of disease of any and every sort. 

As has been said, a single woman usually makes a better 
nurse than one who is married, and the fact that the married 
woman has lost her infant through death does not help matters 
any, for her grief will usually be enough to spoil her milk. 

If the unmarried woman is physically all that could be de- 
sired, she should be given the preference, for the essential thing 
is to secure a good food for the baby. The question is often asked 
if there is not danger that the baby will acquire the disposition and 
character of the wet-nurse, and the best answer is that the proba- 
bilities are exactly the same as that a bottle baby will take on 
the manners and morals of a cow. 

Milk is milk, and if it agrees with the baby its source is a 
matter of no consequence whatever. 

After the nurse has been selected and the baby given into her 
charge the general directions governing the feeding are the same 
as when the infant nurses at its mother's breast. 

Mixed Feeding. — This is the method to be adopted when 
the mother has some milk, of good quality, but not in sufficient 
quantity to, fully satisfy the child. 

The hours for feeding, according to the age of the child, are 
the same whether the baby is at the breast or on the bottle, and 
if the mother has not milk enough to satisfy her infant at every 
feeding she can often skip one or two nursing hours and give 
modified milk in place of the omitted breast feedings. 

This plan should always be tried when the quantity of breast 
milk is below normal and its quality is good, for, as has been 
said, it is better for both mother and child to have the breast 
milk utilized as far as possible. 



376 A NURSE'S HANDBOOK OF OBSTETRICS. 

rhe modified milk to be used in mixed feeding is prepared in 
the proportions suited to the age of the child and given in the 
same quantity that would be allowed if the baby were exclusively 
on the bottle. 

Artificial Feeding, — This is a most important subject and 
one that can only be considered here as it may be applied to a 
normal and perfectly healthy infant. 

The various patented baby foods will not be discussed in any 
way. Directions for their use go with every bottle, and while 
each one claims to be better than all the others, and proves its 
claims by the publication of pictures of fat and usually rhachitic 
babies, they are all more or less bad and of no real value except 
in certain cases where they may be used by the physician's direc- 
tion to tide over a period of travel or to increase the carbohy- 
drates in a food greatly diluted to remove its proteids. 

Condensed milk, like the patented foods, contains too much 
sugar and too little fat to give it any value except on occasions, 
and while it also makes fat babies, these children, like those fed 
exclusively on the advertised baby foods, have no real honest 
strength and are liable to break down in childhood at the first 
attack of any serious disease. 

Mothers often point with pride to healthy grown children, 
and state that they w^ere brought up on this, that, or the other 
food, but the fact remains that if they had been attacked by any 
serious disease of infancy they would have died, when babies 
fed on modified cow's milk might have weathered the gale 
without difficulty. The explanation is that these children were 
fortunate enough to escape any severe disease until they had 
been on a general diet long enough to enable them to resist it. 
That the " baby-food babies " are fat is merely because sugar 
makes fat, and these foods are chiefly composed of sugar, 
which is necessary as a preservative, just as the housewife adds 
sugar to her " preserves " to keep them from spoiling. 

Goat's milk and ass's milk are not worthy of consideration, 
although it is true that their constituents approach more nearly 
the proportions of breast milk than do those of cow's milk. 
The objection to their use lies in the fact that they are not 



ARTIFICIAL FEEDING. 377 

exactly the same as mother's milk and must be modified with as 
much care and attention as is paid to the preparation of cow's 
milk. 

The only milk worthy of serious consideration as a substi- 
tute for breast feeding is that obtained from a herd of healthy 
cows. The milk from one cow, so long regarded as best for 
bottle feeding, is no longer used. It was formerly supposed 
that " one cow's milk " was less liable to change than that from 
mixed milkings, but it is now known that while the milk from a 
herd preserves a very constant average of quality, that from one 
cow is always subject to marked change. 

Laboratories exist in all large cities, which fill prescriptions 
for modified milk. They are known to be reliable and the 
doctor is assured there will be no error in the product. For 
this reason, where available, the feedings are purchased as 
ordered. Some hospitals maintain a diet kitchen service for the 
benefit of physicians requiring such a convenience. Occasionally 
one will be maintained in connection with a Nurses' Directory. 
All milk stations give instruction in milk modification, and such 
instruction is an important feature in the work of a Public 
Health Nurse. It is, however, quite possible for mothers to 
do this properly in the home and if systematized this consumes 
but little time. Where bottled milk is unattainable, cream may 
be removed from a pan with care and fat free milk siphoned 
from the bottom. 

The milk sold in bottles in the cities is usually of fairly good 
quality, owing to existing laws regulating the management of 
dairies and the shipment and sale of milk. The best bottled 
milk to be had in New York is that known as " certified" or 
"'guaranteed," milk and sold by certain dealers only. This dif- 
fers from ordinary bottled milk only in that it is milked, shipped, 
and sold strictly in accordance with suggestions made by a 
committee appointed by the New York County Medical Society 
to investigate the milk supply of the city. Ordinary bottled milk 
may be up to all the requirements of a good food, or it may 
not, but certified milk can always be relied upon in every way. 
If the child is at all feeble, or, in any event, if the parents can 



378 A NURSE'S HANDBOOK OF OBSTETRICS. 

afford the slightly additional expense, certified milk should be 
used instead of the ordinary kind. 

It has been said that mother's milk contains, approximately, 
four per cent, of fat, seven per cent, of sugar, and two per cent, 
of protcids. 

Mixed cow's milk — that is, milk which has been stirred up, 
so that any cream which may have risen is thoroughly mixed 
with the rest of the milk — contains, approximately, four per 
cent, of fat, four per cent, of sugar, and four per cent, of 
protcids. 

At first sight it would seem that the only necessary step in 
modifying cow's milk to meet the requirements of an infant 
would be to dilute it one-half with water, giving fat, two per 
cent. ; sugar, two per cent. ; and proteids, two per cent. ; and 
then adding two per cent, of fat and five per cent, of sugar to 
make the formula read, fat, four per cent.; sugar, seven per 
cent. ; proteids, two per cent. This formula, from a chemical 
stand-point, is exactly the same as that of mother's milk, and it 
would be a proper food for the baby were it not for the fact that 
the proteids of cow's milk differ materially in point of digesti- 
bility from those of breast milk and must be greatly diluted 
before a young infant can assimilate them. By the time the 
child is about three months old its system has become accus- 
tomed to the proteids of cow's milk, the proportions of which 
have been gradually increased from day to day until, by this time, 
the formula is the same as that of mother's milk. 

To prepare milk for an infant under three months of age 
we find that it is most convenient to use, as a basis, cow's milk 
containing twelve per cent, of fat, four per cent, of sugar, and 
four per cent, of proteids. This is called " twelve per cent, 
milk," or " 12-4-4 milk." 

To prepare food for a baby between the ages of three and 
nine months it is most convenient to use cow's milk containing 
eight per cent, of fat, four per cent, of sugar, and four per cent, 
of proteids. This is called " eight per cent, milk," or " 8-4-4 
milk." 

Ordinary mixed cow's milk, containing, as has been said, 



ARTIFICIAL FEEDING. 379 

four per cent, each of fat, sugar, and proteids, is called "four 
per cent, milk," or " 4-4-4 milk." 

To make " eight per cent." or " twelve per cent.", milk it is 
only necessary to add to ordinary mixed (4-4-4) milk the re- 
quired amount of fat in the form of cream. 

Cream is nothing more than milk containing an excess of fat, 
and is of two kinds, — " gravity" cream and " centrifugal" cream. 

" Gravity" cream is that which rises to the top of a milk- 
bottle, or which, in the country, may be skimmed from the milk- 
pans. It contains fat, sixteen per cent. ; sugar, four per cent. ,* 
proteids, four per cent. 

" Centrifugal" cream is that made with a centrifugal machine, 
and is sold in the cities in small sealed bottles as " cream." It 
is about as thick as honey, and contains fat, twenty per cent. ; 
sugar, four per cent. ; proteids, four per cent. 

The problem now is to make either " eight per cent." or 
" twelve per cent." milk by the addition of the proper quantity 
of either " gravity" or " centrifugal" cream to ordinary mixed 
(4-4-4) milk. 

These various formulas may seem a trifle confusing until 
they are placed in order, thus : 



Fat. 
4 per cent. 

8 " 


Sugar. 

4 per cent. 
4 " 


Proteids. 

4 per cent. 
4 " 


12 
16 


4 

4 " 


4 " 
4 " 



20 " 4 ' 4 

It will now be seen that nothing varies but the fat, and that 
the fat varies only in the perfectly regular progression of 4, 8, 
12, 16, 20. 

The first formula is that of ordinary mixed milk, and the 
next two are those of the desired products for use as the basis 
of the baby's food ; while the last two are those of the perfectly 
familiar kinds of cream in every-day use. 

In addition to the method of making " eight per cent." or 
" twelve per cent." milk by mixing cream and ordinary milk in 
proper proportions, the same results can be obtained by removing 
a definite amount of milk from the top of an ordinary quart 



380 A NURSE'S HANDBOOK OF OBSTETRICS. 

milk-bottle in which cream has had time to rise. The method 

of removing this " top milk" and the amount to be removed 

will be taken up later. 

Thus we have three methods at our disposal, — the use of 

" gravity" cream, of " centrifugal" cream, or of " top milk." 
If " twelve per cent." milk is desired, it is made as follows : 
From gravity cream, by adding one part of 4-4-4 milk to two 

parts of gravity cream, thus : 



Fat. 


Sugar. 


Proteids. 


16 


4 


4 


16 


4 


4 


4 


4 


4 


•36 


12 


12 



From centrifugal cream, by mixing equal parts of 4-4-4 milk 
and centrifugal cream, thus : 



Fat. 


Sugar. 


Proteids. 


20 


4 


4 


4 


4 


4 



2)24 



12 



From top milk, by taking nine ounces from the top of the 
bottle as it comes from the dairy. The best way to remove the 
top milk is with the little dipper, holding exactly one fluid ounce, 
devised by Dr. Henry Dwight Chapin and known as the 
" Chapin dipper." The first dipperful is to be taken off with 
a teaspoon, or the milk will be lost when the dipper is lowered 
into the bottle. It is, of course, distinctly understood that the 
milk is to be dipped out and not poured, for any tipping of the 
bottle will disturb the cream and alter the proportion of fat in 
the top milk. 

This " twelve per cent." milk is now to be modified for the 
infant's use, and it is most convenient to prepare twenty ounces 
of food each time in order to make the proportions come right. 

It has been said, in speaking of breast milk, that it should be 



ARTIFICIAL FEEDING. 



38l 



alkaline or neutral in reaction, but never acid. Cow's milk, 
as it reaches the consumer, is always acid, so that it must be 
made alkaline by the addition of lime water or sodium bicar- 
bonate before it is fit for the baby's use. 

The sugar in cow's milk (four per cent.) is normally much 
less than that in mother's milk (seven per cent.), and the addi- 
tion of water, necessary to bring the fat and proteids down to a 
proper amount, reduces the sugar to almost nothing, so that 
sugar must be added to give sufficient sweetness to the food. 

With " twelve per cent." milk as a basis, it is only necessary, 
in preparing food for an infant under three months of age, to 
add lime water, or sodium bicarbonate, milk-sugar, and water in 
proper proportions. The amounts of lime water or sodium bi- 
carbonate and sugar do not change at all, but the milk is in- 
creased and the water proportionately diminished from day to 
day as the child grows older and is able to take stronger food. 

Twenty ounces of food are made at each time, and for this 
amount one ounce each of lime water and milk-sugar are re- 
quired, or sodium bicarbonate, 10 grains (or one-half grain 
to one ounce). When the amount of "twelve per cent." milk 
suited to the age of the child has been added, enough boiled water 
is poured in to make the total amount of food exactly twenty 
ounces and the work is done, thus : 





— bo 


oii 


13 U 

5 <u 


Result. 


Age. 


M 


is 3 


2£ 


&£ 


Fat. 


Sugar. 


Proteids. 


Si 


3i 


3i 


Up to 


.60% 


5% 


.20% 


Second day. 






P 


5 xx 


1.20% 


5% 


.40% 


Third to fourth day. 






3 Hi 




I.8o% 


6% 


.60% 


Fourth to seventh day. 






giv 




2.40% 


6% 


.80% 


Seventh to thirtieth day. 






3v 




3- % 


6% 


I. % 


Second month. 






3vi 




3- 60% 


e% 


I 20% 


Third month. 



* If milk-sugar cannot be obtained, granulated sugar may be used in 
its place. One fluidounce or one Chapin dipperful of granulated sugar 
equals one ounce in weight. Milk-sugar is lighter, and one and one- 
half fluidounces or one and one-half dipperfuls are required to make 
one ounce in weight. 



jga A NURSE'S HANDBOOK OF OBSTETRICS. 

It will be seen that the last formula in the above table, con- 
taining fat, 3.60 per cent.; sugar, six per cent.; and proteids, 
[.20 per cent., is nearly the same as that of mother's milk 
(fat, four per cent.; sugar, seven per cent.; proteids, two per 
cent.) ; and beginning at about the fourth month the infant is 
usually able to take milk of the latter strength. 

" Eight per cent." milk is used for making the 4-7-2 for- 
mula, merely because it is more easily managed than " twelve 
per cent." milk. Like " twelve per cent." milk, it may be made 
either from gravity cream, from centrifugal cream, or from top 
milk. 

From gravity cream, by adding two parts of 4-4-4 milk to 
one of gravity cream, thus : 



Fat. 


Sugar. 


Proteids. 


16 


4 


4 


4 


4 


4 


4 


4 


4 


)24 


12 


12 



From centrifugal cream, by adding three parts of 4-4-4 milk 
to one of centrifugal cream, thus : 



Fat. 


Sugar. 


Proteids. 


20 


4 


4 


4 


4 


4 


4 


4 


4 


4 


4 


4 


)32 


16 


16 



From top milk, by removing with the Chapin dipper sixteen 
ounces of top milk from the full bottle. 

To modify " eight per cent." milk for the infant it is only 
necessary to dilute it one-half with boiled water, which reduces 
the formula to fat, four per cent. ; sugar, two per cent. ; proteids, 
two per cent. ; and then add five per cent, of sugar, which raises 
that ingredient to seven per cent. (5 + 2). 



AMOUNT AT EACH FEEDING. 



383 



In preparing twenty ounces of food the exact formula is as 
follows : 



u 

3£ 


£3> 
§5 


00 <S 




Result. 


Age. 


Fat. 


Sugar. 


Proteids. 


Si 


gi 


3x 


Six 


4% 


l1o 


2% 


Fourth to ninth mouth. 



One ounce of sugar to twenty of food is, of course, exactly 
five per cent, (one in twenty), and as one ounce of lime water 
is used, only nine of water are needed to bring the total quan- 



"NJl 




Fig. 178. — Articles required for the preparation of artificial food. 

tity up to twenty ounces. If sodium bicarbonate is ordered, 
it will be added to the twenty ounces (one-half grain to one 
ounce). 

Having prepared the food properly, according to the age of 
the child, the next point is to ascertain how much is to be given 
at each feeding and how frequently the child is to be given the 
food. 

The hours for feeding are to be exactly the same as those 



j&l A NURSE'S HANDBOOK OF OBSTETRICS 

for nursing at the breast, given on page 363, and the amount 
to be fed at each meal-time is as follows: 

Second day One-half to one ounce. 

Third to thirtieth day One to three ounces. 

Second month Three to four ounces. 

Third month Four to five ounces. 

Fourth to ninth month Five to six ounces. 

It will be seen that, until the baby is about three weeks old, 
twenty ounces of food will last throughout the entire twenty- 
four hours, but after this time it will be necessary to prepare 
twice the quantity, some of which will, at first, have to be thrown 
away. This double amount may be prepared at one time, or, if 
fresh milk is served twice daily, half may be prepared in the 
morning and the other half at night. Usually it is best to prepare 
the entire amount of food for the twenty- four hours at one time 
and keep it on ice until it is wanted. Food should never be 
kept over from one day to another, but a fresh supply should 
be made up each morning. Here again the period between feed- 
ings will be ordered by the doctor, but there is a very strong 
tendency to lengthen this interval to three hours if the child is 
developing normally. 

A convenient method of preparing milk in accordance with 
the foregoing formulae will be found in the use of the Sloane 
Maternity Milk Set, arranged by Dr. Edwin B. Cragin, of 
New York, and consisting of a measuring-glass (Fig. 178) and 
a Chapin dipper. 

The apparatus is used as follows : 

1. Pour into the glass granulated sugar or milk-sugar up 
to the proper mark as indicated on the side. 

2. Add one dipperful (one ounce) of lime water and mix 
by shaking the glass, or ten grains of sodium bicarbonate after 
the dilution is completed. 

3. Add the required number of dipperfuls (ounces) of 
" twelve per cent." or " eight per cent." milk according to the 
age of the child as already explained. 

4. Fill the measuring-glass up to the top graduation (marked 



METHOD OF ADMINISTERING FOOD. 



385 



" 20 oz. of food ") with plain boiled water, barley-water, or oat- 
meal-water. 

During the first month plain water is best, but afterwards 
barley-water may be used or oatmeal- water if the infant is very 
constipated, or the cream may be modified with whey. 

Barley-water may be made of the whole barley or of bar- 
ley flour as follows. From whole barley: Add two teaspoon fuls 

A b 





4 CD 

3 — 
2 — 
1 — 



v_y 



Fig. 179. — Nursing-bottles. A, improper pattern, with long, slender neck; B, proper 
pattern, without neck. 

of washed pearl barley to a pint of water; boil down slowly to 
two-thirds of a pint and strain. From barley flour: Put two 
tablespoonfuls of barley flour into a quart saucepan with one 
and one-half pints of water; boil down slowly to one pint. 
Strain and allow the liquid to set to a jelly. When warmed 
for use it will return to a liquid. 

Oatmeal-water is made as follows : Add one tablespoon- 
ful of well-cooked oatmeal to a pint of water; allow it to sim- 
25 



3 86 



A NURSE'S HANDBOOK OF OBSTETRICS. 



mer slowly for an hour or two until a smooth mixture is ob- 
tained. Strain. 

It is to be distinctly understood that the problem of feeding 
an infant on artificial nourishment is often a most difficult one, 
and that the nurse must never attempt any important modifica- 
tions of diet on her own responsibility, but report at once to the 
physician any unfavorable symptoms that may arise. 

The next question to be considered is the method of adminis- 















~ 1 








- 








— z 








- 












— 




— e 


— 
















































r 


en 


— * 


rf 










~ 


o 




_3 


zZ. 


Z 


— s 


~ 




D 












=: 


O 




sE, 




Fig. 180. — Testing size of opening in nipple. Milk should drop out as indicated, and 
not flow in a stream. 

tering the food. It is, of course, to be taken from a bottle 
through a rubber nipple, and the selection of a proper nursing- 
bottle and nipple are matters of no small importance. 

The shape of the bottle should be such that every part of the 
inner surface can be reached with a swab or brush (Fig. 179). 
Bottles with sharp angles or broad shoulders should never be 
used, for it is impossible to clean them properly, and milk is 
very apt to collect and sour in their many nooks and corners. 

The bottle should be graduated so that it need only be filled 



CARE OF NURSING BOTTLES. 387 

to the amount proper for a given feeding, and so that it will be 
possible at all times to tell exactly how much food the infant has 
taken. 

The best nipples are the plain ones of black rubber, but the 
most important point in the selection of a nipple has to do with 
the size of the hole through which the milk is to come. The hole 
is usually too large, and it is often best to buy nipples without 
any holes at all and make them of the required size with a needle. 

The test consists in holding the bottle, filled with milk and 
with the nipple attached, upside down (Fig. 180). The milk 
should escape drop by drop, and if it runs out in a stream the 
hole is too large. The objection to the large hole is that the 
child nurses too rapidly, and develops indigestion, colic, and 
other disorders. 

The care of the bottles and nipples is another matter of the 
greatest importance, for if any sour milk is allowed to collect 
it will promptly sour fresh milk whenever it is used. 

There should be as many bottles and nipples in commission 
as there are feedings in the twenty-four hours, so that no bottle 
will be used more than once in any day. 

As soon as a nipple has been used it is to be washed thor- 
oughly inside and out with castile soap and hot water, and a 
needle or bristle passed through the hole in the end to force out 
any little curd which may have lodged there. 

All the nipples, after being freshly cleaned and sterilized, 
are placed in a dry sterile Mason jar. Boric acid solution is 
not antiseptic and is rarely properly cared for. Moreover, 
the soaking in solution ruins the rubber. Afterwards, as the 
nipples are used, and after they have been washed, they are 
placed one by one in a cup until all are used, when they are again 
boiled and made ready for the next day. 

The bottles, as has been said, must be so modelled that every 
part of the interior can be reached with a brush or swab. After 
each feeding the bottle is to be washed with castile soap and hot 
water and wiped inside and out, so that no vestige of milk or 
milkiness remains. It is then rinsed thoroughly with fresh 
water and placed on end to drain. Once in every twenty-four 



588 A NURSE'S HANDBOOK OF OBSTETRICS. 

hours all the bottles arc to be boiled. To prevent breakage they 
should be filled with cold water and placed in a vessel containing 
cold water, which is then brought to a boil. After boiling vigor- 
ously for not less than fifteen minutes the vessel is taken from 
the fire and allowed to cool until the bottles can be removed 
without scalding the hand. To attempt to cool them by the 
addition of cold water would be sure to crack some, if not all. 

When the baby is fed, it must be supported in a comfortable 
position, and the bottle is always to be held by the mother or 
nurse in such a way that the nipple will be full of milk. The 
child should never be put to bed with the nipple in its mouth, 
and, as in breast feeding, it should never be allowed to dawdle 
over its meal. If a fair trial shows that it is not anxious for 
its food, the bottle should be taken away and not offered again 
until the next meal time. If the infant persistently refuses to 
take its food there is usually something wrong with the milk, 
and the physician should be consulted. 

Only the proper amount of modified milk for one feeding 
should be put in the bottle, and it should then be warmed to 
body temperature by placing the bottle in a vessel of hot water. 
In cold weather a piece of warm flannel may be wrapped around 
the bottle to keep the milk from growing cold towards the end 
of the feeding. Under ordinary circumstances, a normal child 
should take the entire quantity of food prepared for one feeding, 
and if any is left over at the end of the meal it should be thrown 
away and never returned to the main supply. 

As a rule, city milk of good quality is so carefully cared for 
from the time it is milked until it reaches the consumer that, if 
put on ice at once, it will keep sweet for the entire twenty-four 
hours, but in very hot weather, or when the food has to last for 
a journey of several days, the milk will turn sour, even on 
the ice. 

In such cases it becomes necessary to treat it in a way which 
will destroy the germs of fermentation and so keep the milk 
sweet. This is done by heating the milk to such a degree of 
temperature that the fermentative organisms will be destroyed. 
This, in its most primitive form, is accomplished by the familiar 



STERILIZATION AND PASTEURIZATION. 389 

process of " scalding " the milk, so commonly done by poor 
people who buy cheap milk which is so old that it is just at the 
turning-point when they get it. 

Sterilization is a process which was once in great vogue for 
preserving milk for the use of infants. This consists in placing 
the milk in a " sterilizer " (Fig. 181) and surrounding it with 
live steam for a definite period of time, which raises the tem- 
perature to 212 F. It is true that sterilization destroys all the 
germs in the milk and keeps it sweet for a long period, but it 
has the disadvantage not only of altering the taste to a decided 
degree, but of making the product much more indigestible than 
" raw " milk. On this account milk is not sterilized as much as 
formerly, for under ordinary circumstances it is safer to take the 
slight risk of infection from the comparatively small number 
of bacteria to be found in good milk than to subject the child to 
the greatly increased difficulties of digesting sterilized milk. 
Another reason, however, has done more than anything else to 
do away with the use of sterilized milk, and this is the discovery 
that if the milk is subjected for a considerable period of time 
to a temperature of 167 F. (instead of 212 F.) it will be suffi- 
ciently " sterilized " for all practical purposes, without under- 
going any alteration in taste or increase in indigestibility. 

This process is known as pasteurization, and is accom- 
plished as follows : 

The "pasteurizer" (Fig. 182) is a large tin or copper pail 
with a cover, containing a rack which holds the nursing bottles. 
The rack consists of a number of water-tight cylinders, each 
large enough to admit a bottle, and the pail is so constructed that 
the rack may rest on the bottom and the cover be tightly ad- 
justed, or, with the cover off, the rack may be raised up and 
secured in such a way that the tops of the bottles are about two 
inches above the top of the pail. 

The bottles are those to be used for the feedings, and are 
graduated in ounces and half-ounces. As many bottles as there 
are to be feedings in the twenty-four hours are filled with prop- 
erly prepared milk up to the proper graduation mark, so that 



590 



A NURSE'S HANDBOOK OF OBSTETRICS. 



each bottle will contain one feeding and no more. They are 
then stoppered with ordinary cotton wadding (not absorbent cot- 




Fig. 181. — Steam sterilizer. (Arnold.) 





Fig. 182. — Freeman pasteurizer. 

ton J and placed in the cylinders. Cold water is poured in each 
cylinder around the bottle, and any empty cylinders are filled 



STERILIZATION AND PASTEURIZATION. 391 

with water. Each cylinder is to be filled, and the water should 
not be colder than runs from the faucet. 

The pail, without the rack and bottles, is now filled with 
water up to the rim on the inside and set on the stove to boil. 
As soon as it is boiling furiously it is removed from the fire 
and set on the table or floor, but never on iron or stone, which 
would abstract the heat too rapidly. 

The rack and bottles are lowered at once to the bottom of the 
pail, the cover adjusted snugly, and the apparatus left undis- 
turbed for three-quarters of an hour exactly. 

At the end of this time the pail is placed in the kitchen sink 
or in some other convenient place, the rack raised up and 
secured so that the tops of the bottles will be above the top of 
the pail, and cold water allowed to run in and out, around 
the cylinders and overflowing the sides of the pail, until the milk 
is thoroughly cool. 

The bottles are now placed on ice, and as each feeding time 
comes around, one is taken, the cotton stopper removed, the 
nipple attached, and the contents warmed for the infant's use. 

This milk should be used the same day that it is prepared 
but it will keep sweet for three or four days. 

Many very simple modifications can be made on this principle 
of pasteurization and preservation of milk. Many Infant Wel- 
fare Societies have devised simple substitutes. The emphasis 
is, of course, laid first upon a proper pasteurization and second 
upon the preservation of the feedings at the proper temperature. 

Instead of modifying milk, many different forms of feed- 
ing have been devised, Finklestein's feeding being one most 
often used. 

In general, " raw " milk is better for the baby than milk that 
has been " cooked," and the nurse should never suggest sterili- 
zation or pasteurization on her own responsibility, but con- 
sult the physician if such a process seems to be indicated. 

When, for any reason, it is necessary to remove the child 
from the breast, and the glands are still secreting milk, it will 
be necessary to " dry up " the milk. As a rule, the physician 



392 A NURSE'S HANDBOOK OF OBSTETRICS. 

will give directions for this, but it occasionally falls to the lot 
of the nurse to attend to the matter herself. 

The breasts should be emptied as completely as possible, 
either by massage or with the breast-pump, the ingestion of 
fluids restricted to the smallest amount consistent with ordinary 
comfort, and the snuggest kind of a breast-binder applied and 
left undisturbed for three or four days. There should never be 
any fever, or pain in the breasts, but when the binder is re- 
moved the glands will be found somewhat hard and lumpy. 
This should disappear in the course of two or three days more, 
and the breasts appear soft and free from any trace of milk. 

Drugs Excreted by the Milk. — The Journal of the Ameri- 
can Medical Association (November i, 1902) publishes the fol- 
lowing list of drugs which are excreted by the milk and which, 
consequently, affect the infant : sulphur, rhubarb, senna, jalap, 
indigo, arsenic, bismuth, iron, mercury, potassium iodide, zinc, 
iodine, antimony, opium, oil of anise, oil of dill, garlic, castor 
oil, lead, oil of turpentine, oil of copaiba, all the volatile oils, 
magnesium sulphate (Epsom salt) carbolic acid, quinine, strych- 
nine, and cascara sagrada. The article goes on to say : " The 
elimination of these drugs by the milk is more liable to take 
place when the mother is in a disturbed condition physically and 
when the mammary glands are not in a normal condition. Con- 
sequently care must be observed in prescribing some of these 
preparations for the mother. For example, copaiba and tur- 
pentine will so affect the taste of the milk as to cause the infant 
to refuse the breast. Diarrhoea may be produced in the infant 
by administering castor oil or other of the above purgatives to 
the mother, and the opium preparations will produce the op- 
posite effect on the child through the mother's milk. It is said 
that sufficient action may be produced on the child by administer- 
ing mercury, arsenic, and potassium iodide to the mother." 



XXVI 

Obstetrical Nursing 

The care of obstetric cases presents so many differences 
from ordinary surgical nursing that the nurse requires a few 
special articles for this work in addition to her usual outfit. 

In the first place she should provide herself with an abundant 
supply of dresses and aprons, for the nature of her duties are 



Operating 

Gown 
('front) 




Fig. 183. — Operating gown and case. 



such that, even with the utmost care, she cannot always prevent 
frequent soiling of her aprons at least. In addition to her white 
aprons she should have one large rubber apron for use when 
she is bathing the baby. 

393 



394 A NURSE'S HANDBOOK OF OBSTETRICS. 

A gown (Fig. [83 ), pinned in a towel or tied up in a muslin 
case, and sterilized, should be taken for use at the time of the 
delivery. Nurses often come to a case several days before the 
labor occurs, and, while wearing their uniforms, they are up 
and down stairs and in all parts of the house. Also, as will be 
seen in another chapter, the patient receives an enema at the 
beginning of labor, and frequent trips to the bath-room have to 
be made by the nurse on this account. Keeping these various 
matters in mind, it is evident that the nurse's uniform is any- 
thing but aseptic when labor is in progress, and the gown should 
be worn from the time the patient takes to her bed until after 
the placenta is delivered. 

If complications arise and the nurse must act as a clean nurse, 
she will, of course, scrub up with care, and wear the same long 
sleeved gown, with long rubber gloves, a cap and face guard as 
is worn by the doctor. 

The nurse's arms should be bare to the elbows throughout 
the entire labor, and afterwards several times each day while she 
is attending to the toilet of the patient or bathing the baby. Fre- 
quent rolling up of the sleeves for this purpose soon rumples 
them to such an extent that they present a very disordered ap- 
pearance, highly at variance with the picture of immaculate 
neatness which is always expected of a nurse. Her uniform is 
best preserved by wearing special gowns, made for the purpose. 
The infant is not to be handled by a nurse wearing starched cuffs 
or stiff uniforms. After the morning work about her patients 
the usual nursing uniform may be again worn. 

Two thermometers should be taken to each case, one for the 
mother's temperature and the other, a rectal thermometer, for 
the infant. There should be temperature charts for both mother 
and child in addition to the usual blanks for bedside notes. 
Temperature should always be charted, for its entire course can 
then be understood at a glance, while if it is recorded in any other 
way its significance is not always readily grasped, and unless 
the notes are studied with great care a single, isolated rise of 
temperature may escape the notice of the physician. 

The infant is to be weighed at birth, and afterwards once 




HAMAOCK AND 

SCALED 

ROLLED 




Fig. 184. — Scales and hammock for weighing infant. 



THE INFANT'S WEIGHT. 395 

daily, and as scales are seldom to be had when they are wanted 
for this purpose, it is a good plan for the nurse to add to her 
obstetrics outfit a small scales and hammock, such as is shown 
in Fig. 184. The best scales are large ones with, weights, or the 
old-fashioned " steelyards," for no spring balance is exactly 
accurate; but in the absence of the bulky apparatus, the little 
pocket affair shown in the illustration, and to be had of any 
dealer in surgical supplies, answers very well. The importance 
of weighing the infant daily cannot be over-estimated, and it is 
needless to add that, as the daily variation in weight is always 
a matter of ounces or fractions of an ounce, the same scales 
should be used each time and, unless the infant is placed in the 
scales quite naked, any towels, blankets or diaper should after- 
ward be weighed separately and their weight deducted from the 
total. 

The infant's weight should be recorded daily on a chart, and 
blanks for this purpose, having space for the infant's tempera- 
ture and weight, the mother's temperature and pulse, and all 
the other required data of a maternity case, have been de- 
signed. 

A glass feeding-tube is needed for administering fluids to 
the patient immediately after labor and before she is allowed to 
raise her head. 

Tape for tying the umbilical cord is not mentioned in the list 
of supplies to be provided by the mother, because the physician 
usually includes it in his own outfit, but occasionally it is over- 
looked, and at times, as in cases of precipitate labor, the nurse 
will have to tie the cord before the arrival of the physician. 
For these reasons it is best for her to provide herself with suit- 
able cord ligatures, and the best material for this purpose is 
ordinary linen bobbin tape cut into 12-inch lengths, thoroughly 
washed with soap and water, boiled, and then placed in 95 per 
cent, alcohol in a small glass or agate jar. 

The hypodermic case should contain tablets of ergotin in ad- 
dition to the usual assortment of drugs. Fluidextract of ergot 
is usually used if no anaesthetic has been given. The ergotol is 
ordered for those patients who have been anaesthetized. 



396 A NURSE'S HANDBOOK OF OBSTETRICS. 

To recapitulate, the obstetric nurse needs, in addition to 
the ordinary supplies that she would take to any case : 
Extra aprons. 
Extra uniforms. 
One rubber apron. 
Two operating-gowns, sterilized. 

Two thermometers ; one for mouth, the other for rectum. 
Temperature charts. 
Scales for weighing the infant. 
Weight charts. 
Glass feeding-tube. 

Linen bobbin tape, for tying the umbilical cord. 
Hypodermic tablets of ergotin. 
One safety razor. 
One pair rubber gloves. 
One pair tongue forceps. 
One dressing set of scissors, forceps, clamps. 
One pair long rubber gloves. 
One rectal tube. 

One sterile irrigating can complete. 
One jar of sterile io-yard length uterine packing. 
One rubber catheter. 
One glass catheter. 
One English catheter, No. 8. 
One bottle bichloride tablets. 
Four ounces of lysol. 
One narrow strip of sterile adhesive. 
One bottle saline tablets. 
One ounce of aromatic spirit of ammonia. 
List of articles required by mother, in Chapter XII. 
List of articles required by infant, in Chapter XXII. 



XXVII 

Diets 

The trained nurse will have had a course in dietetics and 
cooking for the sick. No recipes are given here. She should 
have at all times a pocket edition of recipes to be used in the 
nursing of obstetrical cases. 

The diets are classified variously in different hospitals. It 
is essential for the nurse to know how to prepare the following : 

Proper Diet During Pregnancy 

Soups. — Any kind. 

Fish. — Boiled or broiled fresh fish of any kind. Raw oysters 
and raw clams. 

Meat. — Chicken, game, ham, or bacon (broiled), tender lean 
mutton and lamb. Meat is allowed only in perfectly normal 
cases, and then but once daily. 

Farinaceous. — Hominy, oatmeal, wheatcn grits, mush, rice, 
sago, tapioca, arrow-root, stale bread, Graham bread, rye bread, 
brown bread, corn bread, toast, milk toast, biscuits, macaroni. 

Vegetables. — Potatoes, cabbage, onions, spinach, cauliflower, 
Brussels sprouts, asparagus, green corn, green peas, string beans, 
mushrooms, water-cress, lettuce or other salads with oil. 

Desserts. — Plain puddings of rice, arrow-root, sago, or tap- 
ioca ; custards, stewed fruits, ripe raw fruits, and ice cream. 

Drinks. — Plenty of pure water (hot, cold or aerated), at 
least two quarts daily, milk, buttermilk, peptonized milk, kumyss, 
or zoolak. Very little tea or cocoa, practically no coffee, and ab- 
solutely no alcoholic liquors unless specially ordered by the 
physician. 

Such a list is susceptible to many additions and elaborations, 
but in the absence of specific instructions from the physician, 
it will answer perfectly well to give to such patients as insist 
upon positive dietetic directions. 

397 



398 A NURSE'S HANDBOOK OF OBSTETRICS. 

FARINACEOUS DIET 

Breakfast: Tea or coffee (milk and sugar), bread and butter, 
corn bread, rolls, toast, toast and hominy, farina or Indian meal. 

Dinner: Vegetable soups, bread, baked potatoes, tomatoes, 
beans, rice, macaroni, pudding — rice, bread, tapioca or cornstarch 

Supper: Tea (milk or sugar), bread and milk, milk toast, 
hominy, boiled rice or farina. Fruit such as apples, stewed or 
baked, prunes, and pears. 

Diet During Puerperium 

First forty-eight hours: Milk (one and one-half to two pints 
a day), gruel, soup, one cup of tea a day, cocoa, toast and 
butter. 

Second forty-eight hours: Milk toast, poached eggs, porridge, 
soup, cornstarch, tapioca, wine-jelly, small raw or stewed oysters, 
one cup of tea or cocoa per day. 

Third forty-eight hours: Soup, white meat of fowl, mashed 
potato, beets in addition to above. 

After the sixth day return cautiously to ordinary light diet, 
that is, three meals a day, meat of an easily digested character at 
one of them, such as white meat of fowl, tenderloin of beef, 
etc. Also a glass of milk three times a day, between meals and 
before going to sleep at night and a glass in the middle of the 
night. 

Milk Diet. — Eight ounces every two hours of milk with 
water and whey, making ninety-six ounces of fluid in twenty- 
four hours. 

Liquid Diet. — Coffee, tea, hot or cold, in small quantities, 
cocoa, milk, milk-shake, peptonized milk, malted milk, butter- 
milk, whey, plain or with wine, champagne, a fruit juice or 
cream, junket, matzoon, kumyss, albumin, rice, barley-water and 
aerated waters, beef tea, beef juice, bouillon, oyster and clam 
broth, mutton, beef and chicken broth, oatmeal, barley, rice, corn- 
meal, rye, bran, or a mixture of all these cereals may be made 
into gruels. 

Soft Diet. — All soft puddings, fruit whips, ice cream and 



NUTRIENT ENEMATA. 399 

sherberts, custards, well-cooked cereals, thickened soups and 
purees, lentil, pea and barley soups, strained vegetable soups, 
poached and soft boiled eggs, milk toast, plain or peptonized, 
scraped raw beef, and egg-nog. 

Nutrient Enemata 

The amount should be six ounces; it should never exceed 
eight ounces for an adult, or one to two ounces for a child. Its 
administration should follow one hour after a cleansing saline 
enema has been expelled. The patient must be in the usual 
position on the left side; but occasionally it may be better re- 
tained if the patient can be placed and supported with pillows, 
in the knee-chest position. Enemata must be introduced above 
the rectum very slowly. The temperature of the solution must 
be that of the body heat. The tube must be slowly withdrawn 
and pressure placed upon the rectum to assist retention. 

Sugar and Milk Enema. — Grape-sugar, two ounces ; milk, 
six ounces. 

Glucose Solution. — Glucose, one ounce ; water, seven 
ounces. 

Ewald's Enema. — Take the whites of two eggs ; beat in 
four drachms of cold water; cook one drachm of cornstarch in 
glucose solution, 20 per cent. Two ounces of claret. One ounce 
of peptone solution. To be mixed at a temperature below the 
coagulation point of albumin. Amount eight ounces. 

Many combinations of egg, brandy, glucose, dextrose, pep- 
tonized milk, etc., are used. The more usual are beef tea, beef 
peptonoids, digested beef, egg-nog, coffee, and prepared com- 
binations of special foods always with a pinch of salt. Of the 
proprietary substances, the recipe for using is always found in 
the packet containing the purchase. 

Occasionally neurotic patients are fed by means of the stom- 
ach tube. Also in injuries to the neck or cases of poisoning in 
which there has been destruction of the mucous surfaces, and 
with small children, nasal feedings may be given. The nurse will, 
after slowly filling the funnel attached to the stomach tube or 
catheter used, give the required amount, after lubricating the 



400 A NURSE'S HANDBOOK OF OBSTETRICS. 

small tube. The children's size must be used for this purpose. 
It is slowly withdrawn and the patient turned on her face at the 
edge of the bed to control possible regurgitation. 

Hypodermoclysis. — To the ordinary saline solution, brandy 
is sometimes added as a food and stimulant. 

Olive oil and various animal fats are taken up by the skin and 
are sometimes ordered as inunctions. 

The only other special food which concerns the obstetrical 
nurse is one which has been largely discussed but has not re- 
ceived unqualified approval. It represents one of a number of 
similar theories all subscribing to the belief that the size of the 
child in utero can be controlled. 

Prochownik's Diet. — Breakfast: Coffee, four ounces; 
toast, one ounce. 

Dinner: Meat, fish or egg; one vegetable with a sauce or pre- 
pared with fat; lettuce; cheese, one-half ounce. 

Supper: Same repeated ; add bread, butter and milk in small 
quantities, and water, one pint per day. 

To be used during the last three months of pregnancy only 
under the supervision of a doctor. 

In hyperemesis gravidarum, test meals are occasionally or- 
dered. Usually this is withdrawn after one hour by siphoning 
with the stomach tube. 

Reigel and Leube's test meal consists of beef soup, beef- 
steak, white bread and water. 

More often a test breakfast of one white bread roll and a 
cup of hot tea without milk or sugar is ordered. 



APPENDIX 

Technic 

The most scientific knowledge concerning obstetrics may be 
rendered useless by an inefficient technic in hand preparation. 
The nurse should know how to prepare the following: 

Sterile Water. — Boil for twenty minutes. 

Normal Salt Solution. — Sodium chloride, one drachm, 
sterilized ; water, sixteen ounces, boiled and filtered. Boil one 
hour for three successive days. Do not use distilled water. 

Lysol. — An antiseptic saponaceous preparation ; it is used 
as a lubricant, a douche for cleansing; and disinfection of the 
hands, in a one and two per cent, solution. 

Bichloride of Mercury. — Reliable if used sufficiently 
strong. To be effective it must be used in strength of i : 500 for 
hand disinfection. Care must be taken to prevent its absorption 
by mucous surfaces. Occasionally douches are ordered in 
strength of 1 : 2000 at intervals of a few hours ; in these cases 
symptoms of absorption must be closely watched for. Idiosyn- 
crasy for this drug is not uncommon. It is decomposed by blood 
and by albuminoids. 

Carbolic Acid. — As a hand solution it should be used in a 
strength of 1 : 40 or 1 : 100 ; when used for antiseptic cleansing 
of articles and disinfection of exudates, in strength of 1 : 20. 

Biniodide of Mercury. — It does not blacken the nails, and 
is said to be a stronger antiseptic than the bichloride ; it is used 
in a solution of 1 : 1000. 

Sublamin. — A mercury preparation used as are both of the 
mercury solutions named above. 

Cyllin. — A fairly dependable antiseptic ; ordered most often 
as a douche, 1 : 500. 

Permanganate of Potassium. — Used as a douche to in- 
fected surface in weak solution, and as a hot saturated solu- 
26 401 



4 o2 A NURSE'S HANDBOOK OF OBSTETRICS. 

tion tor hand disinfection. It stains all substances coming in 
contact with it, and this stain is removed by immersing the part 
in a solution of oxalic acid of the same strength. It destroys 
much operating room equipment by discoloration and the disin- 
tegrating effect of the oxalic acid. 

Formalin. — Used in twenty to fifty per cent, solution for 
hands, and twelve per cent, solution for douches. 

Alcohol. — Strength, ninety-five per cent. 

Vessels must have been boiled for ten minutes before re- 
ceiving a sterile solution. 

Solutions must be made with boiled water. 

Hands must be scrubbed thoroughly under running warm 
water, the fingers, between fingers, around the nails and up to the 
elbows with any good soap and boiled tampico fibre brush for 
five minutes. Clean the nails, and then scrub for ten minutes, 
using a fresh brush, and gauze sponge on the arms and back of 
the hands. Rinse in biniodide or bichloride of mercury for five 
minutes. Rubber gloves which have been carefully scrubbed, 
turned, tested and boiled for ten minutes are then put on and the 
hands are sterile until something unsterile is touched. If this 
occurs the gloves must be removed and the process repeated. 

The same routine of scrubbing may be followed by immer- 
sion of the forearm in hot saturated solutions of permanganate 
of potassium and oxalic acid ; then by rinsing in solution of bin- 
iodide or bichloride. Alcohol in strength of ninety-five per cent, 
is applied carefully to the fingers and arms by a gauze sponge. 

There are many varied technics named after the surgeons 
who devised them. Most obstetricians have a solution which 
they prefer above all others, and the nurse must see that this is 
properly prepared. The chief points to observe in hand disin- 
fection are the preliminary cleansing of the fingers, hands, and 
arms themselves, and the keeping of them perfectly clean. All 
the substances used are more or less deadly poisons, and they 
must be kept out of the reach of all who are not trained in their 
use. Where pus is present, particularly thorough care must be 
exercised. 



TECHNIC FOR CLEANSING EXTERNAL GENITALS. 403 

TECHNIC FOR CLEANSING EXTERNAL GENITALS 

Two basins, eight inches in diameter, sterile. 

Eight ounces solution of lysol, two per cent 

Eight ounces bichloride solution, 1 : 5000. 

One dozen small sterile cotton sponges placed in each bowl. 

The patient is placed in the dorsal position and draped. The 
pad is removed and a douche pan placed beneath her. Her body 
is supported by pillows placed beneath her back. The hands are 
scrubbed clean, soaked in an antiseptic solution, and discarding 
each sponge as used, the nurse takes a sponge from the bowl 
of lysol with her right hand. This hand she keeps clean by toss- 
ing the sponge to her left hand each time. In this way both her 
right hand and the solutions are kept clean. 

1. Swab across pubes. 

2. Swab down each groin. 

3. Swab across pubes and down each labium majus. 

4. Swab between the labia majora and minora. 

5. Swab between the labia minora. 

6. Repeat the procedure by using the sponges from the bi- 
chloride basin. 

7. If an examination is to be made, place a pledget from the 
bichloride basin between the labia minora. The labia are sep- 
arated by the second and index finger of the left hand; and 
fingers of the sterile hand are used in making the examination. 

8. If a catheterization is to be done, after the labia minora 
are separated, the meatus is carefully cleansed. A pledget is 
placed in the vagina, and a sponge between the labia minora ; 
and the sterile right hand inserts the catheter. 

9. If a douche is to be given a pledget is placed in the rectum. 

10. If a sterile douche, the tip is to be changed after the 
vagina has been douched. 

- It will be seen that this is thorough and reliable. It has been 
used with modifications for years in various hospitals. The 
sponging is always toward the rectum. The sponge is discarded 
after each separate step is carried out. It is a very expeditious 
method, and, if followed as routine, infection is not possible. 



404 A NURSES HANDBOOK OF OBSTETRICS. 

GAUZE SPONGE TECHNIC. 

To prevent the in-bedding in the tissues of small or large 
gauze sponges is one of the gravest responsibilities the nurse has. 
The obstetrical nurse may not be equally keen about this as is a 
surgical nurse and will need the assistance of a special technic 
devised by Dr. C. W. Barrett of Chicago. The usual routine 
of checking up after operation, attaching artery clamps, using 
rolls of gauze, all fail to make the accident impossible. 

Dr. Barrett's Gauze Sponge Techxic. — To laparotomy 
pads of all sizes, a small, smooth, inexpensive snap is attached 
through the medium of an eight- or ten-inch tape. To the la- 
parotomy sheet a large horse blanket pin such as is now com- 
monly used to group instruments, is attached near the wound. 

When each sponge comes to the field of operation it is 
snapped to the safety-pin and is then introduced with safety, 
the number of snaps indicating at all times the number of pads 
in the wound, and the tapes furnish a ready means of reaching 
the pads. 

The snaps are fixed, are not needed for other purposes, and 
are not confused with other instruments used and so remain 
at their task. Any sponge may be detached at will. 

If the snaps have not in any case been attached to the pads 
and sterilized with them, the snaps may be boiled with the in- 
struments, and the tapes then tied to them when the sponges are 
opened. 

This has seemed to help in solving the problem of abdominal 
sponges. 

The nurse, in a properly organized and administered gen- 
eral hospital, will have an invaluable opportunity to see placed 
before her the most effective, efficient, and economic ideals of 
general and obstetrical nursing. The equipment at command em- 
braces, in some instances, the very best in existence. The in- 
struction she receives is the last word of command in the battle 
against invalidism and death. 

She carries out into the world this source of power for ser- 
vice, and will use it in an infinite variety of ways. 



GAUZE SPONGE TECHNIC. 405 

She has found, under the most improbable conditions of 
dirt, squalor and poverty, that the principles of obstetric nurs- 
ing can secure equally safe results if followed explicitly. 

The poor prospective mother of large cities is cared for most 




Fig. 185. — Sponge attached to safety-pin with snaps. 

often by out-patient clinics and dispensaries ; by visiting nurse 
associations employed by various agencies, such as Infant Wei- 



406 A NURSE'S HANDBOOK OF OBSTETRICS. 

fare Organizations, Committees for Reduction of Infant Mortal- 
ity, Public Health Boards, Milk Committees, etc. 

The nurse may or may not be present at the actual delivery, 
concentrating perhaps on a policy of education of mothers and 
saving of babies, with all the social service which this demands. 

This is not always the case, however. She prepares the pa- 
tient for delivery, secures the conditions outlined for private 
cases, as nearly as possible, by the exercise of originality and 
judgment. She assists the doctor in the usual routine way. For 
this work she will require a special bag of supplies. She sees to 
it that the patients will be cared for, and makes the best provi- 
sion possible for their safety and health in the home. 

The nurse usually visits these cases once a day until the pa- 
tient is discharged by the doctor, then as often as necessary. 

The larger part of her duty lies in the definite demonstration 
and teaching of personal and general hygiene and the care of the 
family. This is a large factor in the reduction of infant mortality. 

In rural communities where a nurse elects to work, she will 
find entirely different conditions — scattered, small communities, 
doctors few in number, and transportation inadequate. Public 
Health nurses engaged in rural nursing are meeting and solv- 
ing many obstetrical problems. 

The rural Red Cross nurse is filling a sphere that is taking 
her into still more difficult surroundings, so far as clean ob- 
stetrics is concerned. According to the Superintendent: 

" In sections of the country where there are but few acces- 
sible doctors or even none at all, the relation of the visiting nurse 
to the midwifery question would become a serious problem. Up 
to the present time, however, the forty visiting nurses appointed 
by the Red Cross for service in small towns or rural districts, 
even in the southern mountains, are in communities where there 
is at least one practising physician. Rural nursing, as it is 
being developed by the Red Cross, cannot be well carried on 
unless there is at least one physician in the community under 
whose direction the actual nursing services may be rendered. 

" The rules of nursing organizations affiliated with the Red 
Cross state that the nurse is not allowed to act as a midwife 



RED CROSS NURSING. 407 

where medical attention is available, thus only in an emergency 
are the nurses called upon to act as such and up to date this has 
not been a common occurrence. In fact, it has occurred so 
seldom in the experience of our rural nurses that the need of 
special midwifery training in preparation for rural nursing has 
not yet become evident. 

" Three months thorough training in an obstetrical ward or 
lying-in hospital ought to equip nurses sufficiently to handle 
emergency deliveries as they occur in Red Cross rural nursing. 
It is most advisable that during their obstetrical training, how- 
ever, they be allowed to deliver several normal cases. As a re- 
quirement for appointment to the Service, Red Cross visiting 
nurses are expected to have had practical and theoretical instruc- 
tions in obstetrics." 

Dr. Abraham Jacobi stated in an address before the American 
Medical Association, in 1912, that 50 per cent, of all the births 
in the United States were attended by non-medical women. In 
New York, 42 ; Buffalo, 50 ; St. Louis, 75 ; Chicago, 86 ; later 
figures give the State of Wisconsin 50 per cent. 

Leaving aside utterly the advisability or not of stamping 
midwives out of existence, or educating and continuing this form 
of obstetrical attendance, there is the question of how this 50 
per cent, is to be cared for, for care they must have. 

Different State laws meet the problem in different ways. 
Some recognize and register the midwife, but give her no super- 
vision. In others she is not even registered, but practises with- 
out official recognition. 

This question is being attacked in different ways by different 
communities — by a substitute agency such as the obstetrical hos- 
pital, the out-patient services of such hospitals, the obstetrical 
dispensary, and similar organizations. Pittsburgh has an ob- 
stetrical hospital with a dispensary service in each quarter of 
the city, and a well-organized out-patient service. Manchester, 
New Hampshire, has a scheme of voluntary service of the physi- 
cians, under a head obstetrician. There is an obstetrical clinic 
in connection with a milk station in Baltimore, and a compre- 
hensive organization in Boston, 



408 



A NURSE'S HANDBOOK OF OBSTETRICS. 



The patients are largely foreign, of foreign parentage, and 
negroes. This accounts for the report of the Joint Committee 
of the Chicago Medical Society and Hull House, which conducted 




FiG-186. — Delivery bag. Bellevue Hospital School for Midwives, New York City. 

an investigation of " The Midwives of Chicago." This report 
stated a fact that nurses doing visiting nursing so often encounter, 
and against which argument they are so helpless : " That mid- 
wives now, and probably for years to come, are socially inevi- 



OUT-PATIENT DELIVERY BAG. 



409 




table." Such an alien's social instincts and training are all against 
a physician and hospital care. The patient consenting and the 
husband refusing to permit a doctor's attendance is a fairly 
common complication in a nurse's work. 

Nurses are urged to do their share in teaching and practically 
demonstrating the value of the best obstetrical care available. 
An attitude of disdain toward obstetrical work is fatal for the 
newer ideals of obstetrics. Visiting nurses have endless op- 
portunities for contact and for instructing these women. This 
must be seized upon and a definite educational work can in this 
way be accomplished. 

Bellevue Hospital School for midwives in New York City 
provides its pupils with a bag containing the necessary articles 
for use in the out-patient cases. The outfit consists of a copper 
receptacle covered with denim, the copper receptacle being 
used as a boiler, when contents are removed. 

OUT-PATIENT DELIVERY BAG, CONTENTS 

One white enamel douche can with tubing. 

One enema tip. 

One glass vaginal douche nozzle. 

One medicine dropper (for eyes). 

One medicine glass. 

Two haemostats. 

One pair scissors. 

One thumb forceps. 

One rubber catheter. 

One scale for weighing baby. 

Four ounces green soap. 

Four ounces of alcohol. 

Two ounces cresol comp. 

Two ounces castor oil. 

Two ounces olive oil. 

One ounce of fluidextract of ergot. 

One ounce solution of nitrate of silver, 1 per cent. 

Six sterile towels. 

Six gauze sponges. 



410 A NURSE'S HANDBOOK OF OBSTETRICS. 

Two cord dressings. 

One sterile gown. 

Two packages sterile cotton balls. 

One square rubber sheeting. 

One pair rubber gloves. 

One hand brush. 

One orange-wood stick. 

Nurses visiting patients at their homes require supplies em- 
bracing a somewhat different group. 

Every association and hospital has its individual bag of 
supplies which serves more or less acceptably the class of pa- 
tients visited. The illustration shows that of the Instructive 




Fig. 187. — Nurse's bag. Instructive Visiting Nurse Association of Baltimore, Md. 

Visiting Nurse Association of Baltimore, Md., and will be found 
very complete. 

The nurse is reminded, that though the physicians are in- 
structed to report all births, in many small, new settlements this is 
not done with unfailing regularity. It is quite proper that she 
should suggest to the parents that they ask for a copy of the 
certificate, as the child will require it to enter school, to get work- 
ing papers, to prove citizenship, and to inherit property. In addi- 
tion it makes more possible reliable vital statistics. 

She is again reminded that, as suggested in the paragraph on 
menstruation, if she is informed by a woman in whom menstru- 
ation has ceased of the presence of a vaginal discharge, that this 



NURSE'S BAG. 



411 




Fig. 188. — Contents of bag. Height, 6 inches; length, 12 inches (scant); width, 6 inches; 
weight, empty, 2 lbs.; weight, stacked, 7 lb. 3 oz. 1, rubber lining; 2, safety-pins; 3, 
alcohol, 50 per cent., 3 oz.; 4, mouth wash, 2 oz.; 5, cresol, 2 oz.; 6, aromatic spirit am- 
monia, 1 oz.; 7, liquid green soap, 1 oz.; 8, alcohol, 95 per cent., 1 oz.; 9, boracic acid 
crystals, 2 oz.; 10, talcum powder, pasteboard, adjustable box; 11, thermometers, 3; 
12 and 13, rubber gloves, 1 pair and envelope (made of twilling); 14, instrument case, 
1 (made of twilling); 15, cord-dressings, sterile linen; 16, glass syringe, small, 1; 17, cord- 
tie; 18, enema nozzle, 1 (black rubber); 19, glass nozzle, small, 1; 20, silver probe, 1; 
21, spatula for ointment, 2 (wooden); 22, glass catheter, 2; 23, Halsted clamp, 1; 
24, scissors, 1 pair; 25, rectal tube, 1; 26, rubber catheter, small, 1; 27, instrument pan, 
1 (white granite) ; 28, boracic acid unguent, 2 oz.; 29, unguent oxide zinc, 2 oz.; 30, funnel, 
aluminum, 1; 31, towels, paper, 6; 32, nail-brush, 1; 33, dressing envelope, 1 (made of 
twilling); 34, cotton; 35, gauze; 36, sterile gauze, 2 packages; 37, bandages; 38, adhesive 
plaster; 39, envelope for literature, 1 (made of twilling); 40, literature: pediculosis slips, 
hospital admission slips, bedside charts and envelopes, district cards, directions for patients, 
Thos. Wilson Fuel Saving Society blanks, Thos. Wilson Savings Bank blanks, Babies 
Milk Fund Association slips, Social Service slips, list of hospitals, dispensaries, day 
nurseries, hours for same, forms for Metropolitan Policy Holders and Nursing Manual, 
rules for agents and nurses, tablet for day's work, street directory; 41, day book and 
pencil; 42, nurse's crepe apron. 



412 



A NURSE'S HANDBOOK OF OBSTETRICS. 



suggests a possible cancer of the uterus. She is to be keenly 
sensitive to the duty of advising immediate examination by a 
reputable doctor. Long before the patient suffers pain she may 
be beyond surgical relief, as the progress of uterine cancer is 
most insidious. Occasionally a patient will tell a nurse of this 
symptom before mentioning the matter to any one else. The 
nurse must see her duty clearly, recognize the possible signifi- 
cance, and secure medical attention promptly. Cancer is said 
to be fatal in one woman in every eight and one man in fourteen, 
over forty years of age. It is curable if recognized locally and 
removed. It is incurable, in its later progress. Cancer is not 
impossible in a young woman, but it occurs usually after forty 
years of age. 



KEY TO PRONUNCIATION 



** 



Note that c and g have always their true historical sounds, the 
so-called " hard," as in cat and go. 



a as in ask, fast, chant. 

a as in far, arm, calm. 

a, as in sofa, America, particular. 

a as in hat, mat, man. 

a as in bare, hare, iair. 

a as in American, republican. 

e as in regime, prostrate, usage, 
e as in fete, fate, eight, 
e as in met, men, head. 
i as in there, where, bear. 
e as in fern, earth, bird. 
e as in billet, comet, added. 

i as in piano, medial, studio, 
i as in pique, machine, meet. 
i as in pit, pin, begin. 
i as in pier, peer, clear. 
i as in spirit, necessity. 

o as in obey, potato, biological. 

6 as in no, node, sowl. 

o as in actor, adductor. 

o as in not, odd, what. 

6 as in form, broad, fall. 

o as in atom, gallop. 

6 as in German Gothe, gotten 



u as in instrument, prudential, 
u as in rule, prwdent, move. 
u as in null, cowld, book, 
u as in bwrn, co/onel. 
U as in bwt, bud, come, 
ii as in German Mwller, grim, 
French jms. 

ai as in aisle, isle, bite. 

au as in Fawst, how, now. 

iu as in neutrality, emulate. 

iu as in feud, few, stupid. 

oi as in oil, coin, boy. 

c (hard)=k as in cat, Hng, chasm. 

ch as in loch, German koch. 

cw = qu as in oween, quit. 

dh = th as in thine, this, smooth. 

g (hard) as in go, gallon. 

hw = wh as in where, when. 

j as in /aw, judge, edge. 

ng as in sing, bank. 

ri (French) as in ton, bofi. 

s as in .yon, sit, city. 

sh as in shall, mac/tine, motion. 

th as in thin, breath. 

tsh as in church, much, witch. 

z as in 2one, music. 

zh as in a^ure, cohesion. 



413 



GLOSSARY 

Note. — The definitions and pronunciations in this Glossary are 
taken, in the main, from Lippincott's Medical Dictionary. The refer- 
ences to illustrations refer to cuts and other figures in the body of the 
book. 

Abdomen (ab-do'men). The belly. 

Abdominal (ab-dom'i-nol). Belonging to or relating to the abdomen. 

A. Delivery, delivery of the child by abdominal section. See 

Cesarean Section. 
A. Gestation, ectopic pregnancy occurring in the cavity of the 

abdomen. 
A. Pregnancy. See Abdominal Gestation. 
A. Section. See Ccesarean Section, Cceliotomy, Laparatomy. 
Abnormal (ab-nor'mal). Contrary to the usual or natural structure; 

contrary to the natural condition. 
Abortifacient (a-bor-ti-ie'shient). i. Causing miscarriage. 2. A drug 

capable of causing a miscarriage. 
Abortion (a-bor'shon). The expulsion of the foetus which is not viable; 

expulsion of the fcetus during the first three months of pregnancy. 
Abrasion (ab-re'zhon). 1. The fretting or rubbing off of a patch of skin 
or other covering. 2. A spot rubbed bare of the skin or nearly so. 
3. Denudation by means of chemical action, or by a destructive 
disease-process. 
Abscess (ab's^s). A collection of pus contained in a cavity formed in 
any part of the body by the disintegration and stretching of the 
tissue. 
Acid (as' id). 1. Sour, sharp to the taste. 2. Having the chemical prop- 
erties of an acid. 
Acid (as'id). In chemistry, a compound having the property of com- 
bining with an alkali or a base and thus forming a new compound. 
A. Reaction, a reaction by which litmus paper or solution is 
turned red by the addition of an acid. 
Acme (ac'mi). The highest degree or height of a disease; crisis. 
Accouchement (a-cush-mon'). [French, accoucher, to put to bed, to 
deliver.] The act of being delivered; delivery. 

A. Force, rapid delivery, artificially performed ; as in cases of 
eclampsia or placenta prsevia. 

415 



4 i6 GLOSSARY. 

Accoucheur (a-cu-shtV). [French.] A male midwife; an obstetrician. 

Accoucheuse (a-cu-sruV). [French.] A midwife. 

Acute (fi-ciut'). Sharp-pointed; ending at a point or in an angle less 
than a right angle; severe, as acute pain. In medicine the term is 
applied to diseases having violent symptoms attended with danger 
and terminating within a few days. 

Adnexa (ad-n£?c'saj. Appendages. 

Uterine A., the Fallopian tubes and ovaries. (Fig. n.) 

After-birth (ai' ter-berth). The structures cast off after the expulsion 
of the foetus, including the membranes and the placenta with the 
attached umbilical cord; the secundines. (Figs. 21 and 22.) 

After-pains (af'tir-penz). Those pains, more or less severe, after ex- 
pulsion of the after-birth, which result from the contractile efforts 
of the uterus to return to its normal condition. 

Albolene, Alboline (al'bo-lin). An oily substance resembling white 
vaseline. 

Albuminuria (al-biu-rm'-niu'ri-aj. An albuminous state of the urine. 

Alimentation (a\"i-men-te'shdn). The act of taking or receiving nour- 
ishment. 

Alkaline (al'ca-lain or -lin). Having the properties of an alkali. 

A. Reaction, the reaction in which red litmus paper is turned 
blue by alkalies. 

Alvine (al'vm or al'vain). Belonging to the belly, stomach, or intestines. 
A. Dejections, the faeces. 

Amenorrhcea (a-men-o-ri'aj. Absence or stoppage of the menstrual 
discharge. 

Amnion (am'ni-on). The most internal of the fetal membranes, con- 
taining the waters which surround the foetus in utero. 

Amniotic (am-ni-ot'jc). Pertaining to the amnion. 

A. Sac, the " bag of membranes" containing the foetus before 
delivery. 

Anemia, Anemia (a-ni'mi-aj. Deficiency of blood in quantity, either 
general or local ; also, deficiency of the most important constituents 
of the blood, especially the red blood-corpuscles. 

Anaemic, Anemic (o-n^m'tc). In a state of anaemia. 

Anesthesia, Anesthesia (an-es-thi'zi-3). 1. Loss of feeling or per- 
ception, especially loss of tactile sensibility. 2. The production of 
anaesthesia. 

Anesthetic, Anesthetic (an-^s-th^t'fc). 1. Having no perception or 
sense of touch. 2. A medicine having the power of rendering the 
recipient insensible to pain. 

Anesthetist, Anesthetist (an-^s'thi-U'st). A person who administers 
an anaesthetic. 

Anchylosis (ang-ci-16'sts). See Ankylosis. 



GLOSSARY. 417 

Ankylosis (ang-ct-16'sts). The consolidation of the articulating sur- 
faces of two or more bones that previously formed a natural joint; 
stiff joint. 
Ante-partum (an"ti-par'tum). Before delivery or childbirth. 
Anterior (an-ti'ri-or). Situated before or in front of: 
Antiseptic (an-ti-s^p'tic). 1. Preventing sepsis or putrefaction. 2. A 
substance which prevents or retards putrefaction, — that is, the de- 
composition of animal or vegetable bodies with evolution of offensive 
odors. Among the principal antiseptics are : alcohol, creosote, car- 
bolic acid, common salt, corrosive sublimate (bichloride of mercury), 
vinegar, sugar, charcoal, chlorine, boric acid, tannic acid, and benzole. 
A. Dressing, a surgical dressing containing antiseptics. 
A. Surgery, surgery with proper antiseptic precautions. 
Anus (e'nus). The external opening of the rectum. 
Areola (a-ri'o-laj. The ring of pigment surrounding die nipple. (Fig. 41.) 
Secondary A., a circle of faint color sometimes seen just outside 
the original areola about the fifth month of pregnancy. 
Arterial (ar-ti'ri-al). Belonging to an artery. 

A. Blood, the bright red blood of the arteries which has been 

aerated (charged with oxygen) in the lungs. 
A. Hemorrhage, hemorrhage directly from an artery. 
Artery (ar'te-ri). Any one of the vessels by which the blood is con- 
veyed from the heart to the organs and members of the body. (So 
called because they were supposed by the ancients to contain air.) 
Articular (ar-tic'iu-laj). Relating to joints. 

Articulation (ar-tic-iu-le'shdn). The fastening together of the various 
bones of the skeleton in their natural situation; a joint. The articu- 
lations of the bones of the. body are divided into two principal 
groups, — synarthroses, immovable articulations, and diarthroses, 
movable articulations. 
Ascites (a-sai'tiz). An accumulation of serous fluid in the peritoneal 

cavity ; dropsy of the peritoneum ; dropsy of the belly. 
Asepsis (a-s^p'sis). The absence of septic materials; exclusion of dis- 
ease germs and other causes of septic poisoning. 
Aseptic (a-s^p'txc). Not septic; free from septic matter; not exposed 

to the injurious effects of septic materials. 
Asphyxia (as-fj'c'si-^). Suspended animation; that state in which 
there is total suspension of the powers of body and mind, usually 
caused by interrupted respiration and deficiency of oxygen in the 
blood, as by hanging or drowning. 

A. Neonatorum, A. Neophitorum, " asphyxia of the new-born," 
deficient respiration in new-born children. 
Aspirating Needle (as'pi-re-tmg). A hollow needle attached to a suc- 
tion syringe for withdrawing fluid from the body. 

27 



4T8 GLOSSARY. 

Assimilate (a-sim'i-let). To convert food into nutriment. 
Astringent (as-tn'n'j^nt). I. Binding; contracting. 2. A medicine 

having the power to check discharges, whether of blood, of mucus, or 

of any other secretion. 
Atrophic (a-troi'ic). Relating to atrophy; characterized by atrophy or 

failure of nutrition. 
Atrophied (at'ro-fid). Affected with atrophy ; wasted. 
Atrophy (at'ro-fx). Defect of nutrition; wasting or emaciation with 

loss of strength, unaccompanied by fever. 
Axilla (ac-stTaJ. The armpit. 

Bacteria (bac-ti'ria.). The plural of bacterium. A form of microbes 

or vegetable micro-organisms. 
Basiotribe (be'si-o-traib). An instrument for crushing the base of the 

fetal skull. (Fig. 105.) 
Basiotripsy (be'si-o-tnp-st). The crushing of the base of the fetal skull 

with the basiotribe. 
Bimanual (bai-man'iu-al). Performed with or relating to both hands. 
B. Palpation, examination of the pelvic organs of a woman by 
placing one hand on the abdomen and the fingers of the other 
in the vagina. 
Birth (b£rth). 1. The act of coming into life; the delivery of a child. 
2. That which is born. See Delivery. 

B. Mark, a " maternal mark" or " mother's mark," a mark on 
the skin from birth, — the effect, as some erroneously sup- 
pose, of the mother's longing for, or aversion to, particular 
objects, or of some accidental occurrence affecting her own 
person during pregnancy. 
Bladder (blad'^r). The urinary bladder; a thin distensible sac with 
membranous and muscular walls, situated in the anterior part of the 
pelvic cavity and acting as a reservoir for the urine secreted by the 
kidneys. 
Bland (bland). [Latin, blan'dus, agreeable.] Mild, soothing. 
Bougie (bu'ji or bu-zhe'). A slender instrument primarily designed for 

introduction into the urethra. (Fig. no.) 
Breech (britsh). The nates or buttocks. 

B. Labor or B. Delivery, labor or delivery marked by breech 
presentation. (Fig. 51.) 

Cesarean Operation, Cesarean Section (si-ze'ri-an). [From Julius 
Caesar, — said to have been born this way; more probably from Latin 
ca'dere, to cut.] The operation of cutting into the womb through 
the walls of the abdomen and removing a child when natural delivery 
is impracticable or impossible. 



GLOSSARY. 419 

Capillary (cap't-le-n or co-ptl'o-n). 1. Resembling a hair in size. 
2. Pertaining to a fine hair-like tube ; pertaining to a capillary ves- 
sel. 3. One of the minute blood-vessels which form a net-work 
between the terminations of the arteries and the beginnings of the 
veins. 

Caput (ce'put, Latin, cd'put). 1. The head, consisting of the cranium, 
or skull, and the face. 2. Any prominent object, like the head. 
C. Incuneatum, impaction of the head of the foetus in labor. 
C. Succeda'neum, a dropsical swelling which appears on the pre- 
senting head of the foetus during labor, caused by lack of 
pressure on that part. (Fig. 162.) 

Carbohydrate (car-bo-hai'dret). Any one of a group of chemical com- 
pounds, most of which are the sugars and starches and important 
elements of food. 

Caries (ce'ri-iz). [Latin, "rottenness."] 1. Ulceration of bone. 2. 
Decay of the teeth resulting in the formation of cavities. 

Cartilage (car'ti-lej). 1. Gristle, — a pearly white, glistening substance 
adhering to the articular surfaces of bones and forming parts of the 
skeleton. 2. Any organ or part of an organ made up of this material. 
Ensiform C See Ensiform. 

Casein (ce'si-m). The most important of the proteids of milk; con- 
stituting the basis of cheese in a state of purity. 

Cathartic (ca-thar'tic). 1. Purging or purgative. 2. A medicine which 
quickens or increases evacuations from the intestines, or produces 
purging. 

Catheter (cath'e-t<?r). A surgical instrument like a tube, closed, but 
with one or more perforations towards the closed extremity, for 
passing into canals or passages, — used especially by introduction into 
the bladder through the urethra for the purpose of drawing off the. 
urine. (Fig. 68.) 

Caul (col). A portion of the amniotic sac which occasionally envelops 
the child's head at birth. 

Cell (s<?1). i. Literally, a " cellar" or " cavity;" hence, any hollow space. 
2. One of the minute masses of protoplasm of which organized 
tissue is composed. 

Cephalic (se-ial'ic). Belonging to the head. 

C. Pole, the cephalic extremity of a foetus. 

C. Presentation, presentation of any part of the fetal head in 
labor. (Figs. 43, 46, and 50.) 

Cephalotomy (s^f-o-lot'o-mi). Dissection of the head; also the cutting 
or breaking down of the fetal head. 

Cephalotribe (s^f'a-lo-traib). An instrument for crushing and extract- 
ing the fetal head in cases of difficult labor. 



420 GLOSSARY. 

Cephalotripsy (s*f"a-lo-trtp'si). The operation of crushing the fetal 

head with the cephalotribe. 
Cerebrospinal (scr"i-bro-spai'nal). Relating to the cerebrum and the 
spinal cord. 

C. Fluid, the clear, limpid fluid contained in the ventricles of 
the brain, the subarachnoid spaces and the central canal of 
the spinal cord. 
Cervix (ser'vix). The neck, more particularly the back part; also 
applied to those parts of organs that are narrowed like a neck. 

C. Uteri, the neck of the uterus; the lower and narrower end 
of the uterus. (See Fig. 12.) 
Chloasma (clo-az'maj. PI. chloasmata. A cutaneous affection exhibit- 
ing spots and patches of a yellowish-brown color. The term chlo- 
asma is a vague one and is applied to various kinds of pigmentary 
discolorations of the skin. 

C. Gravidarum, C. Uterinum, chloasma occurring during preg- 
nancy. 
Chorea (co-ri'aj. St. Vitus's dance; a convulsive disease characterized 
by irregular and involuntary movements of the limbs. It usually 
occurs in early life and affects girls more frequently than boys. 
Chorion (co'ri-on). The second, or most external, of the fetal mem- 
branes. 
Chromicized Catgut (cro'mi-saizd). Catgut treated with chromic acid 

for use as ligatures or sutures. 
Chronic (cron'tc). Long continued; lasting a long time; opposed to 

acute. 
Cicatricial (stc-o-tnsh'al). Of the nature of, or relating to, a cicatrix. 
Cicatrix (si-ce'trix). PI. cicatrices. A scar; an elevation or seam con- 
sisting of a new tissue formation replacing tissue lost by a wound, 
sore, or ulcer. 
Circulatory (s^r'ciu-le-to-rt). Relating to, or affecting, the circulation. 
C. System, the system of the animal body consisting of the 
heart, arteries, capillaries, and veins, through which the 
blood circulates. 
Climacteric (clai-mac-ter'ic or clai-mac'te-ric). A particular epoch of 
the ordinary term of life, marked by periods of seven years, at which 
the body is supposed to be peculiarly affected and to suffer consid- 
erable change ; especially, the menopause or grand climacteric. The 
menopause or " change of life." 
Clitoris (ch"t'o-ris). A small, elongated, erectile body at the anterior 

angle of the vulva. (See Fig. 8.) 
Clonic (clonic). Applied to spasms in which the contractions and 

relaxations are alternate. 
Coagulated (co-ag'iu-le-ttfd). Clotted. 



GLOSSARY. 421 

Coaptation (co-ap-te'shon). The fitting together of the ends of a frac- 
tured bone or the edges of a wound. 

Cceliotomy (si-li-ot'o-rm). Abdominal section; surgical opening of the 
abdominal cavity. 

Collapse (co-laps'). 1. A falling or caving in. 2. A state of extreme 
depression or complete prostration of the vital powers, such as 
occurs after severe injury or excessive bleeding. 

Colostrum (co-los'trum). A substance in the first milk after delivery, 
giving to it a greenish or yellowish color. 

C. Corpuscles, large, granular cells found in colostrum. 

Colpeurynter (col-piu-rm't£r). A dilatable bag, used to stretch the 
vagina by introducing the bag in a flaccid condition and then dis- 
tending it by the forcible injection of air or water. 

Colpeurysis (col-piu'n'-si's). Dilatation of the vagina by means of a 
colpeurynter. 

Coma (co'maj. A state of lethargic drowsiness, produced by compres- 
sion of the brain and other causes. 

Comatose (co'ma-tos). 1. Having a constant propensity to sleep; full 
of sleep. 2. Relating to coma. 

Conception (om-s^p'shon). The impregnation of the female ovum by 
the semen of the male, whence results a new being. 

Congenital (c<5n-j<?n'i-tal). Born with a person; existing from or from 
before birth, as, for example, congenital disease, a disease originating 
in the foetus before birth. 

Congestion (con-j^s'tshon). An excessive accumulation of the contents 
of any of the blood-vessels or ducts. 

Conjunctiva (con-jungc-tai'vaj. The delicate mucous membrane lining 
the eyelids and covering the external portion of the eyeball. 

Conjunctival (om-jungc-tai'val). Pertaining to the conjunctiva. 

Conjunctivitis (cdn-jungc-to'-vai'K?). Inflammation of the conjunctiva. 

Constriction (con-stric'shon). A contraction or stricture; that which 
constricts. 

Contraindication (con"tr^-m-di-ce'shon). That which forbids the use 
of a remedy which otherwise it would be proper to exhibit. Any 
condition of disease which renders some special line of treatment or 
some particular remedy undesirable or improper. 

Convalescence (con-vd-\es'ens). The state or period between the re- 
moval of actual disease and the full recovery of the strength. 

Convalescent (con-vd-les'ent). Returning to full health after a disease 
is removed. 

C. Diet, a diet for convalescing patients consisting of any light, 
simple, and appetizing food. 

Convulsion (am-vul'shon). Violent agitation of the limbs or body, 
generally marked by clonic spasms. 



422 GLOSSARY. 

Cornea (cyr'ni-a). The transparent structure forming the anterior part 
of the eyeball. 

Coronal (cor'o-nal). Belonging to, or relating to, the crown of the 
head. 

C. Suture, the suture formed by the union of the frontal bone 
with the two parietal bones. (See Fig. 27.) 

Couveuse (cu-vcz'). An arrangement or apparatus designed for the 
preservation and development of infants prematurely born or other- 
wise feeble. An incubator, which term is in more common use in the 
United States. 

Cranioclasis, Cranioclasm (cre-ni-o-cle's/s, cre'ni-o-clazm). The 
crushing of the fetal skull. 

Cranioclast (cre'ni-o-clast). An instrument used in effecting cranio- 
clasis. (Fig. 104.) 

Craniotomy (cre-ni-ot'o-rm). The opening of the fetal skull when nec- 
essary to effect delivery. 

C. Scissors, strong S-shaped scissors for use in craniotomy. 
(Fig. 109.) 

Crotchet (crotsh'et). A curved instrument for extracting the foetus 
after craniotomy. No longer used. 

Curd (curd). The coagulum which separates from milk upon the addi- 
tion of acid, rennet, or wine. It consists of casein with most of the 
fatty elements of the milk. 

Curettage (ciu-r^t'ej). The act of using a curette. 

Curette (ciu-r^t'). [French.] 1. A sort of scraper or spoon used in 
removing granulations, foreign bodies, incrustations, etc., from the 
walls of normal or other cavities in the body. Most commonly used 
for removing diseased tissue or foreign matter such as retained pla- 
cental tissue from the walls of the uterus. (Fig. 120.) 2. To use a 
curette. 

Curettement (ciu-r^t'ment) . Same as Curettage. 

Cutaneous (ciu-te'ni-us). Belonging to the skin. 

Cutis (ciu'tts). The skin, consisting of the cutis vera and the epi- 
dermis. Also, the cutis vera, or true skin. 

Cyanosis (sai-a-no'szs). A blue color of the skin resulting from con- 
genital malformation of the heart from some defect of the 
pulmonary circulation by which the venous blood is not wholly 
oxygenated. 

Cyanotic (sai-o-not'ic). Relating to cyanosis; affected with cyanosis. 

Decapitation (di-cap-t-te'shon). The removal of the head of the foetus 
in embryotomy. 

Decidua (di-sid'iu-3). The membranous structure produced during ges- 
tation and thrown off from the uterus after parturition. It consists 



GLOSSARY. 423 

of the greatly changed uterine mucous membrane and the fetal 
envelopes. 

D. Reflexa, that portion of the decidua which is reflected over 

and surrounds the ovum. 
D. Serotina, " late decidua," that portion of 'the decidua vera 

which becomes the maternal part of the placenta. 
D. Vera, that portion of the decidua which lines the interior of 
the uterus. (Fig. 19.) 
Decomposition (di-com-po-zzsh'on). 1. The separation of compound 
bodies into their constituent parts or principles ; analysis. 2. Putre- 
factive decay. 
Delirium (di-h'r't-um). A derangement of the functions of the brain 
characterized by incoherent and wandering talk, illusions, and un- 
steady gait. 
Delivery (di-\iv'er-i). [French, delivrer, to free, to deliver.] 1. The 
expulsion of a child by the mother, or its extraction by the obstetric 
practitioner. 2. The removal of a part from the body; as delivery 
of the placenta. 
Denudation (d<?n-iu-de'shon). The laying bare of any part of an animal 
or plant ; the stripping off of the integument, whether by a surgical 
or by a pathological process. 
Denuded. Laid bare. 
Diagnosis (dai-ag-no'sfs). The art or science of signs or symptoms by 

which cne disease is distinguished from another. 
Diagnostic (dai-ag-nos'Uc). 1. Relating to diagnosis. 2. Distinctive; 

of sufficient value to enable one to make a diagnosis. 
Diaphoresis (dai"a-fo-ri'sJs). A state of perspiration; profuse per- 
spiration ; sweat. 
Diaphoretic (dai"a-fo-r^t'ic). 1. Causing perspiration. 2. A medicine 

having the power to produce diaphoresis. 
Diathesis (dai-athV-sis). A particular habit or disposition of the body 
which renders it peculiarly liable to certain diseases ; constitutional 
predisposition. 
Diet (dai'^t). The food proper for invalids. Also, the regulation of 
food to the requirements of health and the cure of disease. 
D. -Sheet, a written or printed dietary. 
Dietary (dai'e-te-ri). A system or course of diet; a regulated allowance 

of food given to each person daily. See Diet-Sheet. 
Dietetic (dai-e-tet'ic) . Belonging to the taking of proper food, or to 
diet. 

D. Treatment, treatment of disease by careful and scientific 
regulation of the diet. 
Differential (dif-e-rerisha\). Making a difference; showing a differ- 
ence; distinguishing. 



424 GLOSSARY. 

D. Diagnosis, the determining of the distinguishing features of 

a malady when nearly the same symptoms belong to two 

different classes of disease, as in gout and rheumatism or 

epilepsy and eclampsia. 

Dilute, Diluted (dai-liut', dai-liu'tcd). Mixed, weak; reduced in 

strength ; rendered weaker by the addition of water. 
Disintegration (dts-m-ti-gre'shon). The separation of the integrant 

parts or particles of a body. 
Diuresis (dai-iu-ri'sis). Increased discharge of urine, from whatever 

cause. 
Diuretic (dai-iu-r^t'tc). i. Belonging to diuresis; causing diuresis. 

2. A medicine which increases the flow of urine. 
Dropsy (drop's*'). The accumulation of serous fluid in the tissues or in 

the thorax or abdomen. 
Duct. A tube or canal by which a fluid is conveyed. 
Ductus (duc'tus). A duct. 

D. Arteriosus, " arterial duct," a blood-vessel peculiar to the 
foetus, communicating directly between the pulmonary artery 
and the aorta. (See Figs. 28 and 29.) 

D. Venosus, " venous duct," a blood-vessel peculiar to the foetus, 

establishing a direct communication between the umbilical 
vein and the descending vena cava. (See Figs. 28 and 29.) 
Dysmenorrhea (dis-men-o-n'q.) . Difficult and painful menstruation. 
Dyspnoea (dis-pni'aj. Difficult or labored breathing. 
Dystocia (dis-to'si-aj. Difficult, slow, or painful birth or delivery. It 
is distinguished as Maternal or Fetal according" as the difficulty is 
due to some deformity on the part of the mother or on that of 
the child. 

Placental D., difficulty in delivering the placenta. 

Eclampsia (^c-lamp'si-aj. Any epileptiform seizure, especially recurrent 
convulsions, not immediately due to disease of the brain. 

Puerperal E., a convulsive attack coming on in women during 
or after labor and due probably to uraemia. 
Ectopic (ec-top'ic). Out of place. 

E. Gestation, gestation in which the foetus is out of its normal 
place in the cavity of the uterus. See Extra-uterine Preg- 
nancy. 

E. Pregnancy, same as Ectopic Gestation. 
E. Sac, the amniotic sac in ectopic gestation. 
Eczema (ec'ze-ma). A superficial affection of the skin characterized by 
. a smarting eruption of small vesicles, generally crowded together, 
without fever, and not contagious. 
Eczematous (^c-z^m'a-tus). Belonging to or affected with eczema. 



GLOSSARY. 



425 



Eliminate (i-h'm't-net). To put out or expel; to throw off or set free. 

Elimination (i-h'm-z-ne'shon). The act of expelling from the body as 
waste products. 

Eliminative (i-h'm'i-ne-ttv). 1. Tending to increase elimination or ex- 
cretion. 2. Any agent or remedy that promotes excretion. 

Emaciation (i-me-shi-e'shon). The state of being or becoming lean. 

Embolism (em'bo-h'zm). The obstruction of an artery or a vein by a 
clot of coagulated blood, or by any body brought from some point 
away from the site of obstruction. See Embolus and Thrombus. 
Air E., embolism in which the obstruction consists of air-bubbles. 

Embolus Om'bo-lus). A piece of blood-clot which has been formed in 
the larger vessels in certain morbid conditions and has afterwards 
been forced into one of the smaller arteries so as to obstruct the 
circulation. 

Embryo (^m'bri-6). The product of conception in utero before the end 
of the third month of pregnancy; after that it is called the foetus. 
(Fig. 24.) 

Embryotomy (^m-bri-ot'o-mi). The destruction or separation of any 
part or parts of the foetus in utero when circumstances exist to 
prevent delivery in the natural way. 

Emetic (i-met'ic). 1. Having the power to excite vomiting. 2. A 
medicine which causes vomiting. 

Emmenagogue (^-m^n'a-gog). A medicine having the power to promote 
the menstrual discharge. 

Emulsion (i-mul'shon). An oily or resinous substance suspended in 
water through the agency of mucilaginous or adhesive substances. 
Milk is a natural and perfect emulsion. 

Emunctory (i-mungc'to-n). 1. Excretory. 2. Any excretory duct of 
the body. 

Enema (<m'e-maj. A medicine to be thrown into the rectum; a clyster; 
a rectal injection. 

Enervation (>n-£r-ve'shon) . Weakness ; languor ; lack of nerve stimulus. 

Ensiform (en' si-iovm.) . Like a sword; sword-shaped. 

E. Appendix, Cartilage, or Process, the extremity of the ster- 
num or breast-bone. 

Epidemic (>p-f-d<?m'ic). 1. A term applied to any disease which seems 
to be upon the entire population of a country at one time, as distin- 
guished, on the one hand, from sporadic disease (or that which 
occurs in isolated cases) and, on the other, from endemic disease 
(or that which is limited to a particular district). 2. An epidemic 
disease ; the season of prevalence of any epidemic disease. 

Epilepsy (*p't-kp-si). The falling sickness; a chronic non-febrile 
nervous affection, characterized by seizures of loss of consciousness, 
with tonic or clonic convulsions ("fits"). The ordinary duration of 



426 GLOSSARY. 

a fit is from five to twenty minutes. The frequency of the attacks 
or fits varies immensely ; in some cases they occur daily and in 
others at intervals of ten years or more. 

Epileptic (rp-i-lrp'tic). i. Belonging to epilepsy. 2. A person affected 
with epilepsy. 

Epileptiform (ep-i-\cp'ti-iorm) . Like epilepsy. 

Episiotomy (<?p"i-sai-ot'o-rm). Surgical or obstetrical incision of the 
vulvar orifice. 

Ergot (er'got). A drug having the remarkable property of exciting pow- 
erfully the contractile force of the uterus, and chiefly used for this 
purpose, but its long-continued use is highly dangerous. Usually 
given in the fluid extract. Dose, 3 ss— ii. 

Ergotin (er'go-tin). The extract of ergot or active principle of ergot. 
Dose, Vib to y 2 grain. 

Ergotole (er'go-to\). A proprietary preparation of ergot said to possess 
double the strength of the official fluid extract. Dose, gss-i. 

Erosion (i-ro'zhon). An eating or gnawing away: similar to ulceration. 

Evacuation (i-vac-iu-e'shon). 1. The act of discharging the contents of 
the bowels, or defecation. 2. The discharge itself; a dejection or 
stool. 

Evisceration (i-vis-e-re'shon). Taking the bowels or viscera out of the 
body. 

Obstetric E., removal of the abdominal or thoracic viscera of 
the foetus in embryotomy. 

Exacerbation (eg-zas-er-be'shon) . 1. An increased force or severity 
of the symptoms of a disease. 2. The stage or time of periodical 
aggravation in certain fevers. 

Excoriation (<?cs-co-ri-e-shon). Abrasion or removal, partial or com- 
plete, of the skin. 

Excrement (Vcs'cri-ment). Originally, anything that is excreted: 
usually applied to the alvine faeces. 

Excrementitious (>cs"cri-m£n-U'sh'us) . Belonging to excrement. 

Excrete (^cs-crit'). To separate from the bodily tissues useless matter 
which is to be cast out of the system. 

Excretion (Vcs-cri'shon). 1. The separation of those fluids from the 
blood which are supposed to be useless, as urine, perspiration, etc. 
2. Any such fluid itself. 

Exostosis (^c-sos-to'sis). An exuberant growth of bony matter on the 
surface of a bone. 

Expiration (ecs-pi-re'shon). The act of breathing out or expelling air 
from the lungs. 

Expiratory (ecs-pair'e-to-n). Relating to or of the nature of expiration. 

Expire (<?cs-pair'). 1. To expel the breath; to breathe out. 2. To die. 

Expulsive (ecs-puYsiv). Tending towards, promoting, or causing ex- 
pulsion. 



GLOSSARY. 427 

E. Pains, labor-pains occurring during the expulsive stage and 

accomplishing the expulsion of the foetus. 
E. Stage, that stage of labor which follows complete dilatation 
of the uterine cervix, during which the expulsion of the 
foetus takes place; the second stage of labor. 
Exsanguination (^c-sang-gui-ne'shon). The state of being without 

blood. 
Extension Ocs-ten'shon). The reverse of flexion. 

Extravasation (^cs-trav-a-se'shon). The escape of any fluid of the 
body, normal- or abnormal, from the vessel, cavity, or canal that 
naturally contains it, and its diffusion into the surrounding tissues. 
Extra-uterine (ecs-tr^-iu'te-rm). Outside of the uterus. 
E. Life, life after birth. 

E. Pregnancy, pregnancy in which the foetus is contained in 

some organ outside of the uterus. 

Faeces (fi'siz). The alvine excretions or excrement. The matter ex- 
pelled from the bowels at stool. 

Fallopian (fa-16'pi-an). [Relating to G. Fallopius, a celebrated Italian 
anatomist of the sixteenth century.] 

F. Tubes, the oviducts, — two canals extending from the side of 

the fundus uteri to the ovaries. (Fig. 11.) 
F. Pregnancy, pregnancy occurring in the Fallopian tubes, — 
same as tubal pregnancy. 
Febrile (fi'bn'l, or ieh'vi\). Belonging to fever; feverish. 
Fecal (fi'cal). Relating to faeces; containing faeces. 
Fecundation (f<?c-un-de'shon). The act of impregnating or the state of 
being impregnated; the fertilization of the ovum by means of the 
male seminal element. 
Fenestrated (f?n-£s-tre't<?d). Pierced with openings. 
Fetus (fi'tus). The same as Foetus. The spelling fetus is preferable 
from a linguistic point of view ; but the other is far more common 
in professional literature. 
Fillet (iiYet). A noose for making traction on the foetus in difficult 

labor. Never used now. 
Finger Cot. A thin rubber covering for the finger to protect it from the 
air or from septic discharges. Occasionally used as a dressing to 
cover a slight wound or abrasion of the finger. 
Fissure (fish'iur). A crack or narrow opening. 
Flex (fkx). To bend, as a joint or a jointed limb. 
Flexion (fiVc'shon). The act of bending; the state of being bent. 

F. Stage, that stage of labor in which the head of the foetus 
bends forward. 
Fcetus (fi'tus). The child in utero from the end of the third month of 




428 GLOSSARY. 

pregnancy till birth. (See Fig. 25.) During the first three months 
the product of conception is known as the embryo. 

Fontanel, Fontanelle (fon-ta-nd'). The quadrangular space between 
the frontal and two parietal bones in very young children. This is 
called the anterior f. and is the familiar " soft spot" just above a 
baby's forehead. A smaller, triangular one (posterior f.) sometimes 
exists between the occipital and parietal bones. 

Foramen (fo-re'm^n). A hole, opening, aperture, or orifice, — especially 
one through a bone. 

F. Ovale, an opening situated in the partition which separates 
the right and left auricles of the heart in the fcetus. 

Forceps (idr'seps). An instrument consisting of two arms which can be 
approximated and used for grasping a part. (Figs. 83, 84, 85, and 86.) 

Formula (for'miu-laj. 1. A short form of prescription in practice in 
place of the more full instruction in the Pharmacopoeia. 2. A concise 
mode of indicating by symbols the chemical constituents of a com- 
pound or the result of chemical changes. 

Fornix (for'mcs). PI. fornices. An arch; any vaulted surface. 

F. of the Vagina, the angle of reflection of the vaginal mucous 
membrane onto the cervix uteri. 

Fourchette (fur-sh<?t') . [French, "fork."] The posterior angle or 
commissure of the labia majora. 

Friable. Easily reduced into small pieces. 

Function (fungc'shon). A power or faculty by the exercise of which 
the vital phenomena are produced; the special office of an organ in 
the animal or vegetable economy. 

Fundus (fun'dus). The base or bottom of any organ which has an 
external opening considered as the top. 

F. Uteri, the base of the uterus, which is to be considered as 

upside down with the top (os) pointing downward. (See 
Fig. 12.) 
Funis (fiu'm's). A cord, — especially the umbilical cord. 

Galactagogue (ga-lac'ta-gog). 1. Causing the flow of milk. 2. Any 

drug which causes the flow of milk to increase. 
Gastric (gas'tn'c). Belonging to the stomach. 
Genital (j>n'*'-tal). 1. Belonging to generation. 2. Relating to the 

genital organs. 
Genupectoral (j<?n-iu-p<?c'to-ral). [Latin, ge'nu, knee, + pec'tus, 

breast] Relating to the knees and chest. 

G. Position, that posture in which the patient rests on the knees 

with the thighs upright, the head and upper part of the chest 
being on the table or bed. The knee-chest position. 



GLOSSARY. 429 

Germicidal (j7r'rm-sai-dal). Destroying germs. 

Germicide (j^r'mi-said). A substance which has the power of destroy- 
ing micro-organisms. 

Gestation (j<?s-te'shon). The condition of a pregnant female; preg- 
nancy ; gravidity. 

G. Sac, the sac enclosing the embryo in ectopic pregnancy. 

Gland (gland). An organ consisting of blood-vessels, absorbents, and 
nerves, for secreting or separating some particular fluid from the 
blood. 

Glandular (glcrn'diu-la.r). Pertaining to or like a gland in appearance, 
function, or structure ; also, furnished with glands. 

Glans (glanz). An acorn-shaped organ. 

G. Clito'ridis, the bulbous extremity of the clitoris. 
G. Pe'nis, the nut-like head or end of the penis. 

Graafian Follicles or Vesicles (graf'i-an). Small spherical bodies in 
the ovaries, each containing an ovum. (Fig. 15.) 

Granulation (gran-iu-le'shon). The process by which little grain-like, 
conical fleshy bodies form on ulcers and suppurating wounds, filling 
up the cavities, and bringing nearer together and uniting their edges. 
2. One of the bodies thus formed. 

Gravid Uterus (graved). The uterus in the impregnated state or during 
gestation. 

Gravidity (gre-vid'i-ti) . The condition of a woman who is pregnant; 
gestation ; pregnancy. 

Gynecic, Gynecic (ji-m'sic). Relating to the female sex or to women. 

Gynecologist, Gynecologist (j«i-i-col'o-j»st). One who is skilled in 
gynaecology. 

Gynecology, Gynecology (jth-i-col'o-JO- A treatise on woman and the 
peculiarities of her constitution as compared with man ; the science 
which treats of the female constitution and particularly of the dis- 
eases and injuries of the female genital organs. 

Hemorrhage, Hemorrhage (hem'o-rej). Escape of the blood from its 
natural channels ; bleeding. 

Hemorrhoid, Hemorrhoid (h^m'o-roid). A pile; a vascular tumor im- 
mediately within (internal h.) or just outside of (external h.) the 
anus. Hemorrhoids are termed blind when they do not cause hemor- 
rhage and bleeding when they do. 

Hernia (h£r'-ni-aj. the displacement, through an abnormal opening, of 
an organ or tissue, most commonly of a portion of the intestine from 
the cavity in which it is naturally contained ; a " rupture." 

Hydrometer (hai-dromV-ter). An instrument for ascertaining the spe- 
cific gravity of fluids. 

Hygiene (hai'ji-in). That department of medicine which has for its 
direct object the preservation of health or the prevention of disease. 



430 GLOSSARY. 

Hygienic (hai-ji-rn'tc). Belonging to hygiene. 
Hypersecretion (hai"pcr-si-cri'shon). Excessive secretion. 
Hypertrophy (hai-ptVtro-fi). Enlargement of a part or an organ, espe- 
cially when due to over-nutrition. 
Hypodermatic, Hypodermic (hai"po-der-mat't'c, hai-po-der'mic). i. Con- 
nected with the application of medicine under the skin ; subcuta- 
neous. 2. A medicine introduced under the skin. 

H. Injection, an injection beneath the skin of drugs or nutrient 

solutions. 
H. Needle, the hollow needle forming the nozzle of a hypo- 
dermic syringe. 
H. Syringe, a small syringe with a fine-pointed nozzle for in- 
jecting fluids under the skin. 
Hypogastric Arteries. Same as the umbilical arteries which accompany 

and form part of the umbilical cord. 
Hysteria (h/s-ti'ri-aj. A functional disease often observed in young 
unmarried women, in which there may be a simulation of almost any 
disease and a great lack of self-control. 

Iliac (iTi-ac). Belonging to the ilium or the flanks. 

I. Artery, either of two arteries, right and left, given off from 

the abdominal aorta and dividing to form the external and 

internal iliac arteries on each side of the body. 

I. Fossa, a broad and shallow cavity at the upper part of the 

inner surface of the ilium. 

Ilium (tTi-um). PI. il'ia. The haunch bone; the broad, flat, upper 

portion of the innominate bone. (Fig. i.) 
Impregnation (im-pr^g-ne'shon). The act of making, or state of being 

pregnant ; fecundation. 
Incise (m-saiz'). To cut, as with a knife. 
Incised Wound (m-saizd' wund). A wound made by a sharp cutting 

instrument. 
Incision (m-sizh'on). A wound* made by cutting, — especially an opera- 
tion-wound. 
Incubator (m'ciu-be-tor). See Couveuse. 

Indurate, Indurated (m'diu-ret, -re-ted). Made hard; hardened. 
Induration (m-diu-re'shon). The state or process of hardening of the 
tissues from any cause ; the hardening of any part from the effect 
of disease ; any part or tract of abnormally hardened tissue. 
Infection (m-fec'shon). i. The communication of a disease by personal 
contact with the sick or by means of effluvia arising from the body 
of the sick ; contagion. 2. The agent by which a communicable 
disease is conveyed ; a contagium. 

Septic I., infection caused by septic germs. See Septic. 



GLOSSARY. 431 

Infectious (m-f^c'shus). Capable of extension by infection; con- 
tagious ; easily communicated. 
Inflammation (m-fla-me'shon). A state of disease characterized by 

redness, pain, heat, and swelling, attended or not with fever. 
Infusion (m-fiu'zhon). To pour in or upon. In surgery the injection 
of hot normal salt solution ( 6 /io per cent.) into a blood-vessel. 
Venous I., when the injection is made into a vein. 
Arterial L, when the injection is made into an artery. 
Subcutaneous I., when the injection is made into the subcu- 
taneous connective tissue, usually under the breast, over the 
shoulder-blade, or in the outer side of the thigh. 
Ingest (in-jest'). To throw in, or put in, as food into the stomach. 
Ingesta (m-j^s'taj. Food taken into the body by the mouth. 
Ingestion (m-j<?s'tshon). The act of putting or taking food into the 

stomach. 
Inhalation (m-he-le'shon). A drawing of the air into the lungs; the 

inspiring of medicated or poisonous fumes with the breath. 
Insomnia (m-som'ni-g.). Want of sleep; wakefulness; chronic or 

habitual privation of sleep. 
Innominate (i-nom'i-net). Having no name; unnamed. 

I. Bone, the hip-bone, composed of the ilium, ischium, and os 
pubis. (Fig. 1.) 
Innominatum (i-nom-i-ne'tvm) . The innominate bone. (Fig. I.) 
Inspiration (m-spi-re'shon). The act of drawing in the breath. 
Inspiratory (m-spai're-to-n). A term applied to muscles which by their 
contractions increase the dimensions of the chest and thus produce 
inspiration. 
Intertrigo (m-tir-trai'go). An excoriation or galling of the skin about 
the anus, axilla, or other part of the body, with inflammation and 
moisture. 
Intestine (in-tes'tin) . The long membranous tube, continuing from the 
stomach to the anus, in the cavity of the abdomen ; the bowels or 
entrails. 
Inunction (m-ungc'shon). The act of rubbing in an ointment, or 
simply of anointing. This is a method of applying certain substances 
to the cutaneous surface, the object being to promote their absorption. 
In utero. Inside the uterus. 

Inversion (m-v^r'shon). A turning upside down, inside out, or end for 
end. 

I. of the Uterus, the state of the womb being turned inside 
out, caused by violently drawing away the placenta before it 
is detached by the natural process of labor. (Fig. 125.) 



432 GLOSSARY. 

Involution (m-vo-liu'shon). i. A rolling or pushing inward. 2. A 
retrograde process of change the reverse of evolution : particularly 
applied to the return of the uterus to its normal size and condition 
after parturition. 

Irrigation (ir-i-ge'shon). 1. The continual application of water or of 
a lotion on an affected part ; the washing out of a cavity by a 
stream of water. 2. The liquid used in washing out a cavity or a 
wound. 

Ischium (zs'ci-um). The posterior and inferior bone of the pelvis, dis- 
tinct and separate in the fcetus or the infant; or the corresponding 
part of the innominate bone in the adult. (Fig. 1.) 

Jaundice (jan'dis, or jondis). Yellowness of the skin, eyes, tissues, 
and secretions generally from impregnation with bile-pigment; 
icterus. 

Knee-chest Position. See Genupectoral Position. 



Labia (le'bi-aj. The nominative plural of labium. Lips or lip-like 
structures. 

L. Majora, the folds of skin containing fat and covered with 

hair which form each side of the vulva. 
L. Minora, the nymphse, or folds of delicate skin inside of the 
labia majora. (Fig. 8.) 
Labor (le'bor). Parturition; the process by which a foetus is separated 
and expelled from its mother. 

Dry L., when there is a lack of amniotic fluid. 

Induced L., when brought on by outside interference. 

Missed L., when the normal processes cease and the fcetus is 

retained. 
Precipitate L., when of abnormally short duration. 
Premature L., when occurring before the normal time. 
Spontaneous L., when without any assistance. 
Laceration (las-£-re'shon). The act of tearing; a rent or torn place 

in any tissue ; a wound made by tearing. 
Lactation (lac-te'shon). The act or period of giving suck ; the secretion 

of milk; the time or period of secreting milk. 
Lacteal (lac'ti-al). Resembling or relating to milk. 

L. Calculus, a concretion of thickened milk occurring in the 

breast. 
L. Swelling, swelling of the breast from accumulation of milk 
due to obstruction of the lacteal ducts. 
Lactiferous (lac-tif'^-rus). Practically the same as lacteal. 



GLOSSARY. 433 

Lactometer (\ac-tom'e-ter). An hydrometer for determining the specific 

gravity of milk. 
Lambdoid, Lambdoidal (lam'doid, lam-doi'dal). Having the shape of 
the Greek letter A 

L. Suture, the suture between the occipital and two parietal 
bones. (See Fig. 27.) 
Laparotomy (lap-a-rot'o-mi). Cutting into the abdominal cavity through 

the flank ; less correctly, abdominal section at any point. 
Larynx (lar'mgcs). That portion of the air-passages between the base 

of the tongue and the windpipe. 
Laxative (\ac'sa-tiv). 1. Slightly purgative or aperient; mildly cathar- 
tic. 2. A laxative medicine. 
Lesion (li'zhun). A hurt, wound, or injury of a part; a pathological 

alteration of a tissue. 
Lethargic (te-thar'jtc). Belonging to lethargy; in a state of lethargy. 
Lethargy (leth'ar-jt). A state of marked drowsiness, stupor, or sleep 

which cannot easily be driven off. 
Leucorrhcea (liu-co-ri'a.). A whitish discharge from the female genital 

organs ; the whites. 
Ligature (h'g'ci-tshur). A thread or cord used for tying around an 

artery, vein, or any growth. 
Linea (h'n'i-a). PI. linea. A line or thread. 

L. Alba, the central tendinous line extending from the pubic 

bone to the ensiform cartilage. 
Line^e Albicantes, shining whitish lines upon the abdomen 
caused by pregnancy or distention; striae gravidarum. 
(Fig. 30.) 
Liquor (h'c'or, or lai'cwor). A liquid. 

L. Amnii, the fluid contained within the amnion in which the 

foetus floats. 

Lithotomy Position (h'-thot'o-rm). The position of a patient flat on 

the back with legs and thighs flexed and thighs separated widely; 

also called the dorso-sacral posture. 

Lochia (16'ci-aJ. The discharge from the genital canal during several 

days subsequent to delivery. 
Lochial (16'ci-al). Relating to the lochia. 
Lying-in (lai"mg-m'). The puerperal state. 
L. Fever, puerperal fever. 

L. Hospital, a hospital where pregnant women are cared for 
before, during, and after labor. 

Malaise (mal-ez'). [French, tnal, ill, -f- aise, ease.] Discomfort or un- 
easiness ; indisposition. 

Malposition (mal-po-zish'on). An abnormal position, as of the foetus; 
a displacement. (See Fig. 52.) 
28 



434 GLOSSARY. 

Malpractice (mal-prac't/s). Practice contrary to good judgment, 
whether from ignorance, carelessness, or a wrong motive. 

Mamma (mam'aj. PI. mamma. ["Ma-ma," the instinctive cry of an 
infant.] The breast of the human female. (Fig. 14.) 

Mammary (mflm'5-n), Belonging to the mamma, or female breast. 

Mania (me'ni-q). A form of insanity marked by an exalted but per- 
verted mental activity. 

Maniacal (me-nai'a-cal). Affected with mania; resembling mania. 

Manual (man'iu-al). Relating to, or performed by, the hands. 

Massage (mo-sazh'). The systematic therapeutical use of rubbing, 
kneading, stroking, slapping, straining, pressure, and other passive 
exercises applied to the muscles and accessible parts. 

Maternal (me-ter'nal). Relating to or originating with the mother. 

Maternity (me-t£r'nI-U)- I. Motherhood; the condition of being a 
mother. 2. A lying-in hospital. 
M. Nurse, an obstetric nurse. 

Meatus (mi-e'tus). A passage; an opening leading to a canal, duct, or 
cavity. 

M. Urinarius, the external orifice of the urethra. (Fig. 8.) 

Meconium (mi-co'ni-um). The dark-green or black substance found in 
the large intestine of the foetus or newly born infant. 

Median (mi'di-an). In the middle; between others; medial or mesial. 

Melancholia (md-an-co'li-aj. A form of insanity (and a condition of 
mind bordering upon insanity) in which there is great depression of 
spirits, with gloomy forebodings. 

Melancholic (me\-an-co\'ic). Belonging to melancholia. 

Membrane (m^m'bren). A skin-like tissue used to cover some part of 
the body, and sometimes forming a secreting surface. Mucous mem- 
branes line cavities and canals which communicate with the external 
air, as the nose, mouth, etc. Serous membranes line cavities which 
have no external communication, such as the pleural and peritoneal 
cavities. They have a smooth, glossy surface from which exudes a 
transparent serous fluid that gives to them their name. When this 
fluid is secreted in excess dropsy of those parts is the result. The 
word " Membranes" is also used to indicate the amniotic sac which 
surrounds the foetus. 

Menses (m<?n'siz). [PI. of Latin mensis, month.] The periodical 
monthly discharge of blood from the uterus; the catamenia. 

Menstrual (rwn'stru-al). Relating to. or caused by, the menses. 

Menstruate (tnm'stru-et). To have the catamenial flow; to have the 
" monthly flow." 

Menstruation (men-stru-e'shon). The monthly period of the discharge 
of a red fluid from the uterus; the function of menstruating. It 
occurs from puberty to the menopause. 



GLOSSARY. 



435 



Menopause (m^n'o-poz). The period at which menstruation ceases; 

the " change of life." 
Microscopic (mai-cro-sc<?p'ic). So minute that it can be seen only by 

, means of a microscope. 
Midwife (mid' waif). A woman who delivers women with child; a 

female obstetrician. 
Miscarriage (mis-car'ej). The expulsion of the foetus at any time 

between the third and sixth month of gestation. More generally 

used to indicate the expulsion of the foetus at any time up to the 

period of viability of the child. 
Mons Veneris (monz ve'neris). The eminence in the upper and anterior 

part of the pubes of women. (Fig. 8.) 
Monster (mon'ster). A foetus born with a redundancy or deficiency, a 

confusion or transposition, of parts. For example, a child born 

with two heads or with but one eye. 
Monstrosity (mon-stros'i-tO- A monster. 
Monthlies (munth'liz). The menses. 
Morbid (mor'bid). Diseased or pertaining to disease. Morbid is used 

as a technical or scientific term in contradistinction to the term 

healthy. 
Morbidity, Morbility (mor-btd't-tt, mor-bil't-tt). I. The condition of 

being diseased. 2. The amount of disease or illness existing in a 

given community; the sick-rate. 
Mother's Mark. A nsevus ; a birthmark. 
Mucosa (miu-co's^). A mucous membrane. 
Mucous, Mucose (miu'cus, miu'cos). Belonging to or resembling 

mucus ; covered with a slimy secretion or with a coat that is soluble 

in water and becomes slimy. 

M. Membrane. See Membrane. 
Mucus (miu'cus). The viscid liquid secretion of a mucous membrane. 
Multigravida (mul-ti-grav't-d^.). A woman who has been pregnant 

several times, or many times. 
Multipara (mul-ttp'a-r^). A woman who has borne several, or many, 

children. 
Mummification (mum"*'-fi-ce'shon). The shrivelling up and compres- 
sion of a dead foetus. 



Nsevus (ni'vuj). A natural mark or blemish; a mole, a circumscribed 

deposit of pigmentary matter in the skin. 
Nates (ne'tiz). The buttocks. 
Nausea (no'shaj. Originally, sea-sickness. Any sickness at the stomach 

similar to sea-sickness. 
Navel (ne'vel). The umbilicus. 

N. String, the umbilical cord. 



436 GLOSSARY. 

Nephritis (nr-frai'tts). Inflammation of the kidney. 
Neurotic (niu-rot'ic). Of or belonging to the nerves; nervous. 
Neutral (niu'tral). Neither one nor the other; indifferent. 

N. Reaction, a reaction which is neither acid nor alkaline. 9 
Nitrogenous (nai-trojV-nus). Containing nitrogen ; nitrogenized. 
Nodular (nod'iu-lar). Belonging to a nodule; having the form of a 

nodule. 
Nodule (nod'iul). A little node; a small rounded mass. 
Normal (nor'mal). Regular; without any deviation from the ordinary 

structure or function; according to rule. 
Nutrient (niu'tri-ent). i. Nutritious; nourishing. 2. A nutritious sub- 
stance. 

N. Enema, an injection of nutrient fluid into the rectum for 
the purpose of maintaining the strength of the system when, 
for any reason, food cannot be taken into the stomach. 
Nutriment (niu'tn'-m^nt). Nourishment. 
Nutrition (niu-trish'on). The assimilation or identification of nutritive 

matter to or with our organs. 
Nutritious (niu-tn'sh'us). Nourishing; affording nourishment or 

nutrition. 
Nutritive (niu'tri-Uv). Pertaining to nutrition; capable of repairing 
the waste of the body ; nutritious. 

N. Enema, same as Nutrient Enema. 

Obstetric, Obstetrical (ob-stet'ric, ob-stet'n-caj). Belonging to mid- 
wifery or obstetrics. 

Obstetrician (ob-st<?-tn'sh'an). An accoucheur, or man-midwife; a 
practitioner of obstetrics ; one who is skilled in obstetrics. 

Obstetrics (ob-st^t'n'cs). [Latin, obstetrix, midwife.] The art of as- 
sisting women in child-birth and of treating their diseases during 
pregnancy and after delivery; midwifery. 

Occiput (oc'si-put). The back part of the head. 

CEdema (i-di'maj. A swelling from effusion of serous fluid into the 
cellular substance; a dropsical swelling. 

Oligohydramnios (ol"i-go-hai-dram'ni-os). Deficiency of the amniotic 
fluid. 

Opacity (o-pas'i-ti) . 1. Incapability of transmitting light; the reverse 
of transparency. 2. Any defect in the transparency of the cornea, 
from a slight film to an intense whiteness. 

Organ (or'gan). A part of an animal or vegetable capable of perform- 
ing some act or office appropriate to itself, as, for example, the 
heart, the lungs, or the stomach. 

Os. Mouth. 

O. Externum {external os), the external opening of the canal 
of the cervix. 



GLOSSARY. 437 

O. Internum (internal os), the internal opening of the canal 

of the cervix. 
O. Uteri, " mouth of the uterus." (See Fig. 12.) 
Os. [PI. ossa.] A bone. 

O. Innominatum, the innominate bone. (Fig. 1.) 
Osmosis (os-mosis). The power or action by which liquids are impelled 

through a moist membrane and other porous partitions. 
Osteomalacia (os'ti-o-ma-le'si-aj. A disease marked by progressive 

softening of the bones from loss of their earthy constituents, so that 

they become flexible and fragile and unable to support the body. 

The disease affects adults, especially pregnant women, and is fre- 
quently fatal. 
Ova. Plural of ovum. 

Ovarian (o-ve'ri-an). Belonging to the ovary. 
Ovary (6'va-rt). The sexual gland of the female in which the ova are 

developed. (Fig. 13.) There are two ovaries, one at each side of 

the pelvis. 
Oviduct (6'W-duct). The Fallopian tube which conveys the ovum from 

the ovary to the uterus. (See Fig. 13.) 
Ovisac (6'vj-sac). Same as Graafian Follicle. 
Ovulation (ov-iu-le'shon). The growth and discharge of an unimpreg- 

nated ovum, usually coincident with the menstrual period. 
Ovule (ov'iul). A "little egg." The ovum before its discharge from 

the Graafian follicle. 
Ovum (6'vum). 1. An egg, particularly a hen's egg. 2. The female 

reproductive cell. The human ovum is a round cell about V120 of an 

inch in diameter, developed in the ovary. (Fig. 23.) 
Oxytocic (oc-st-to'sic). 1. Accelerating parturition. 2. A medicine 

which accelerates parturition. 

Pack the Uterus. To tampon the uterus. See Tampon. 
Pallor (pal'or). Paleness; loss of color. 

Palpation (pal-pe'shon). [Latin, palpa're, to handle gently, to feel.] 
Examination by the hand or by touch ; manipulation of a part with 
the fingers for the purpose of determining the condition of the 
underlying organs. 

Obstetric P., palpation of the abdomen of the pregnant woman 
to determine the size, position, and presentation of the 
foetus. 
Palpitation (pal-pt-te'shon). Convulsive motion of a part: applied 
especially to the rapid action of the heart, whether caused by disease 
or by excitement. 
Papilla (pa-pii'aj [PI. papil'lce.] Originally, a "pimple." Any minute, 
nipple-like eminence. 



438 GLOSSARY. 

Parietal (pe-rai'r-tul). Belonging to the parietes or walls of any 
cavity, organ, etc. 

P. Bones, the two quadrangular bones that form the transverse 
arch of the cranium. 

Paroxysm (par'oc-s/zm). An evident increase of symptoms which after 
a certain time decline ; a periodical fit or attack ; the periodic fits or 
attacks which characterize certain diseases. 

Paroxysmal (par-oc-siz'mal). Relating to, or characterized by, par- 
oxysms ; occurring in paroxysms. 

Parturient (par-tiu'ri-^nt). Bringing forth; child-bearing. 

P. Canal, the canal through which the fcetus passes in child- 
birth : it consists of the uterus and vagina regarded as one 
canal. 
P. Woman, a woman about to give birth to a child. 

Parturition (par-tiu-n'sh'on). Expulsion of the fcetus from the uterus; 
also the state of being in child-bed ; labor. 

Paternal (pe-tcr'nal). Relating to or originating with the father. 

Pathologic, Pathological (path-o-log'ic, -log't-cal). Belonging to 
pathology ; morbid. 

Pathology (pa-thol'o-ji). The doctrine or consideration of diseases; 
that branch of medical science which treats of diseases, their nature 
and effects. 

Pelvimeter (pel-vim' e-ter). An instrument for measuring the diameters 
and capacity of the pelvis. (Fig. 5.) 

Pelvimetry (pel-vim' e-tri). The obstetrical measurement of the pelvis. 
It may be performed with the hand (Digital p.) or with a pelvimeter 
(Instrumental p.). When the measurements are made on the outside 
of the body it is External p.; when within the vagina, Internal p.; 
and when both within the vagina and outside of the body, Com- 
bined p. (See Figs. 6 and 7.) 

Pelvis (pel'vis). [Latin, " basin."] The bony cavity forming the lowest 
part of the trunk. It is bounded behind by the sacrum and coccyx ; 
at the sides and in front by the ossa innominata. (Fig. 1.) 

Penis (pi'm's). The male organ of copulation. 

Perforator (p^r'fo-re-tor). An instrument for boring into the cranium. 
(Fig. 103.) 

Perineorrhaphy (per" i-m-or' a- fi). Suture of the perineum; the oper- 
ation for the repair of lacerations of the perineum. 

Perineum (p<?r-?-ni'um). The space between the genital organs and the 
anus. (See Fig. 9.) 

Periphery (pe-rii'e-ri). The circumference of a circle; the parts most 
remote from the centre. 

Peristalsis (pev-i-stal' sis,) . The peculiar movement of the intestines 
and other tubular organs, like that of a worm in its progress, by 



GLOSSARY. 439 

which they gradually propel their contents. Peristalsis is produced 
by the combined action of circular and longitudinal muscular fibres. 

Peristaltic (per-i-stal'tic). Relating to peristalsis. 

Peritoneal (p^r"*-to-ni'al). Relating to the peritoneum. 

Peritoneum (p^r"j-to-ni'um). A strong serous memb'rane investing the 
inner surface of the abdominal walls and the viscera of the abdomen. 

Peritonitis (p^r"i-to-nai'bs). Inflammation of the peritoneum; popu- 
larly, " inflammation of the bowels." 

Pernicious (p2r->msh'us). Baleful; deleterious; highly dangerous : as 
pernicious anaemia, or pernicious vomiting. 

Perspiration (p^r-spi-re'shon). [Latin, perspirare, to breathe every- 
where.] i. Sweat. 2. The process or function of sweating. 

Pessary (p<?s'o-n). An instrument, usually in the form of a ring or a 
ball, for introduction into the vagina, to prevent or remedy the 
prolapse of the uterus. 

Phantom (fan'tom). The small effigy of a child used to illustrate the 
progress of labor. 

P. Pregnancy, feigned, hysterical, spurious, or false pregnancy; 

pseudocyesis. 
P. Tumor, a tumor of the abdomen due to flatus or contraction 
of the abdominal muscles. 

Pharmacopoeia (far"ma-co-pi'^). An authoritative book containing a 
description of the medicines and drugs in use in a country. The 
United States Pharmacopoeia is published by authority once in ten 
years, after it has been revised by a national convention of physicians 
and pharmacists. 

Phenomenon (fi-nomV-non). PI. phenomena. An appearance; any- 
thing remarkable. In pathology it is synonymous with symptom. 

Phlegmatic (fteg-mat'ic). Dull; sluggish; cold; morose; not easily 
excited. The oppositie of nervous when applied to one's disposition. 

Physical (iiz'i-ca\). Belonging to nature. 

Physiological (iiz"i-o-\o]'i-ca\). Belonging to physiology. 

Physiology (fiz-'i-oYo-ji). The doctrine of vital phenomena, or the 
science of the functions of living bodies. 

Physique (fi-zic')- Natural constitution; corporeal form; personal 
endowments ; the physical or exterior parts of a person. 

Pigment (pig'ment). I. Any dye or paint. 2. The normal coloring- 
matter of the organs and fluids of the body. 

Pigmentary (pig'men-tz-ri). Relating to pigment. 

Pigmentation (pig-men-te' shon) . The formation or deposition of pig- 
ment. 

Pipette (pi-pet'). A tube used in withdrawing or adding small quan- 
tities of fluid ; used chiefly in chemical and pharmaceutical work. 



440 GLOSSARY. 

Placenta (ple-scn'ta). The circular, flat, vascular structure in the 
impregnated uterus forming the principal medium of communication 
between the mother and the child. (Figs. 21 and 22.) 

P. Previa, that condition in which the placenta is situated inter- 
nally over the mouth of the womb, often proving a cause 
of excessive hemorrhage. 
Pledget. A little plug. A wad of lint, cotton, or the like, applied as to 
a wound or a sore to keep out the air, absorb discharges, or retain 
a dressing. 
Plethora (pkth'o-ra.). A condition characterized by fulness of the 
blood-vessels, strong heart action and pulse, florid complexion, and 
general plumpness of the body. 
Plethoric (pli-tho'nc, or pkth'o-nc). Relating to plethora; full of 

blood. 
Pleura (plu'raj. A serous membrane, divided into two portions and 

lining the right and left cavities of the chest or thorax. 
Pleural (plu'ral). Relating to the pleura. 
Podalic (po-dal'j'c). By means of or relating to the feet. 

P. Version, version by which the feet of the child are made to 
present. (See Fig. 75-) 
Pole (pol). The extremity of the axis of a sphere. 
Polyhydramnios (pol"i-hai-dram'ni-os). Hydramnion; excess in the 

amount of the amniotic fluid. 
Posterior (pos-ti'ri-or). Situated dorsally or to the rear. 
Postnatal (post-ne'tal). Occurring after birth. 
Post-partum (post-par'tum). After or subsequent to child-birth. 

P. Chill, a chill, lasting several minutes, often following expul- 
sion of the child. 
P. Hemorrhage, hemorrhage following delivery. 
P. Shock, the exhaustion immediately following labor. 
Postpuerperal (p6st-piu-er'p?-ral) . Occurring after child-birth. 
Pregnancy (pr^g'nan-si)- [Latin, prceg'nans, literally "previous to 
bringing forth."] The state of being with young or with child. The 
normal duration of pregnancy in the human female is two hundred 
and eighty days, or ten lunar months, or nine calendar months. 
Pregnant (pr^g'nant). With young or with child. 
Premature (pri-me-tiur'). Before it is ripe. 

P. Infant, an infant born after the period of viability but before 

the last two weeks of normal pregnancy. 
P. Labor, labor which takes place during the last three months 

of the natural term, but before its completion. 
P. Respiration, respiration on the part of a child before it is 
completely born. 



GLOSSARY. 441 

Premonitory (pri-mon'i-to-n). Advising beforehand; giving previous 
warning; precursory; applied to symptoms which give an indication 
or warning of the advent or onset of certain diseases, — for instance, 
chills, during the invasion of fever. 

P. Pains, painless uterine contractions before the beginning of 
true labor. 
Prepuce (pri'pius). The fold of skin which covers the glans penis in 
the male. 

P. of the Clitoris, the fold of mucous membrane which covers 
the glans clitoridis. 
Primigravida (prai-rm-grav'i-daj. PI. primigravidco. A woman who 

is pregnant for the first time. 
Primipara (prai-rm'p'a-raj. PI. primiparco. A woman who has brought 

forth her first child. 

Prognosis (prog-no' sis). The foreknowledge of the course of a disease 

drawn from a consideration of its signs and symptoms ; the art of 

forecasting the progress and termination of any given case of disease. 

Prognostic Symptom (prog-nos'tic). A symptom from a consideration 

of which a prognosis of any particular disease is formed. 
Prognosticate (prog-nos'ti-cet). To make a prognosis. 
Prolapse (pro-laps')- A falling down, partial or complete, of some 
viscus, in its latest stage accompanied by protrusion so as to be partly 
external or uncovered. 

P. of the Cord, descent of the umbilical cord on the bursting of 

the bag of waters. (Fig. 126a.) 
P. of the Uterus, descent of the uterus, " falling of the womb." 
Promontory (prom'on-to-n). A small projection; a prominence. 

P. of the Sacrum, the superior or projecting portion of the 
sacrum when in situ in the pelvis, at the junction of the 
sacrum and the last lumbar vertebra. 
Prophylactic (proi-i-lac'tic). Belonging to prophylaxis ; preventive. 
Prophylaxis (proi-i-\ac'sis). The art of guarding against disease; the 
observation of the rules necessary to the preservation of health or 
the prevention of disease. 
Proteid (pro'ti-fd). Any one of a class of organic compounds forming 
the important part of animal and vegetable tissue. The proteid in 
milk is the part that forms the curd. 
Pruritus (pru-rai'tus). An intense degree of itching. 
Psychic, Psychical (sai'dc, sai'd-col). Belonging to the mind or 

intellect. 
Ptyalism (tai'a-h'zm). Increased and involuntary flow of saliva. 
Puberty (piu'b£r-ti)- The age at which the generative organs become 

functionally active. 
Pubic (piu'btc). Belonging to the pubis. 



44-' GLOSSARY. 

Pubis (piu'b/s). The os pubis or pubic bone forming the front of the 

pelvis. (Fig. i.) sometimes, but incorrectly, written pubes. 
Pudenda (piu-oVn'da). Plural of pudendum. 
Pudendal (piu-dcn'dal). Relating to the pudendum. 
Pudendum (piu-drn'dum). [Latin, pude're, to have shame or modesty.] 
The external genital organs or parts of generation of either sex, but 
especially of the female : also used, perhaps more correctly, in the 
plural (pudenda). (See Fig. 8.) 
Puerpera (piu-cr'p£-raj. A woman in child-bed, or one who has lately 

been delivered. 
Puerperal (piu-cr'p^-ral). Belonging to, or consequent on, child- 
bearing. 

P. Convulsions, epileptiform convulsions occurring immediately 

before or after child-birth. 

P. Eclampsia, same as puerperal convulsions. See Eclampsia. 

P. Fever, a severe febrile disease which sometimes occurs in the 

puerperal state, usually about the third day after child-birth, 

accompanied by an inflamed condition of the peritoneum, 

due to septic infection. 

P. Insanity or Mania, insanity occurring in females towards 

the end of pregnancy or soon after delivery. 
P. State, the condition of a woman in, and immediately after, 
child-birth. 
Puerperium (piu-^r-pi'ri-um). The state or period of a woman in 

confinement. 
Pulmonary (puTmo-ne-rt). Of the lungs or belonging to the lungs. 
Pulsation (pul-se'shon). Any throbbing sensation resembling the beat- 
ing of the pulse ; the heart's action extending to the arteries, felt in 
any part of the body. 
Purpura (pur'piu-raj. A disease in which there are small distinct 
purple specks and patches on the surface of the body, with general 
debility but not always fever. 
Purpuric (pur-piu'rze). Relating to purpura. 

Purulent (piu'ru-lent). Consisting of pus; of the nature of pus. 
Pus (pus). A bland, cream-like fluid found in abscesses or on the 
surface of sores ; matter ; " corruption." 

Rational (rash'on-al). Conformable to reason or to a well-reasoned 
plan ; reasonable. Also applied to the mental state of a person. 

R. Symptoms, symptoms communicated by the patient to the 
physician; subjective symptoms. 
Reaction (ri-ac'shon). i. Increase of the vital functions succeeding 
their depression. 2. The phenomena resulting from the action of two 
or more substances upon each other. 



GLOSSARY. 443 

Rectal (r^c'tal). Connected with or pertaining to the rectum. 

R. Alimentation, the administration of nourishment by means 
of enemata containing nutritive matter. 

Rectum (r^c'tum). The last portion of the large intestine, terminating 
at the anus ; the lower bowel. 

Reflex (ri'flecs). Reflected; caused by the conveyance of an impression 
to the central nervous system and its transmission through a motor 
nerve to the periphery. 

Regurgitation (ri-g^r-ji-te'shon). A flowing back; a flowing the wrong 
way: applied, for example, to the passive vomiting of infants and 
to the rising of food in the mouth of adults. 

Relaxation (ri-lac-se'shon). The reverse of contraction or tension; 
looseness; want of muscular tone or vigor. 

Remission (ri-rmsh'on). An abatement or diminution of symptoms. 

Renal (ri'nal). Belonging to the kidney. 

Respiration (r^s-pt-re'shon). The function of breathing, including both 
inspiration and expiration. 

Restitution (r^s-tt-tiu'shon). The act of restoring or returning some- 
thing, — particularly, rotation of the fetal head after its expulsion 
from the vagina, so that it looks in the same direction as it did 
before it entered the pelvic brim ; external rotation of the fetal head. 
(Fig. 46.) 

Resuscitation (ri-sus-t-te'shon). The act of restoring to life those who 
are apparently dead. 

Retained Placenta (ri-tend')- A placenta not expelled by the uterus 
after labor. 

Retention (ri-t^n'shon). The keeping back or stoppage of any of the 
secretions, particularly the urine. 

R. of Urine, a condition in which the urine is retained in the 
bladder and cannot be discharged voluntarily. 

Rhachitic (re-cit'i'c). Relating to or affected with rhachitis or rickets. 
R. Pelvis, a pelvis deformed by rickets. 

Rhachitis (re-cai'Us). Rickets. 

Rickets (ric'ets). A disease of childhood in which there is a lack of 
the earthy salts in the bones, with resultant curvatures and deformi- 
ties of them, affections of the liver and spleen, and a condition of 
general weakness. Nourishing food, fresh air, exercise, and tonics 
furnish the best mode of treatment. 

Rotation (ro-te'shon). The act of turning round; the motion of any 
solid body about an axis. 

R. Stage of Labor, that stage of labor at which the presenting 
portion of the foetus rotates or turns round. 

Rupture (rup'tshur). 1. Bursting or breaking of a part. 2. Hernia. 



444 GLOSSARY. 

Sacrum (se'crum). The triangular bone wedged between the ossa in- 
nominata, forming the posterior wall of the pelvis, articulating above 
with the vertebral column and below with the coccyx, and formed 
by the fusion of the five sacral vertebrae or segments. (Fig. i.) 

Sagittal (soj'i-tfil). Relating to, or shaped like, an arrow. 

S. Suture, the suture which unites the parietal bones. (Fig. 27.) 

Saliva (se-lai'vaj. The colorless ropy fluid in the mouth secreted by 
certain glands and glandular structures in the mouth ; the spittle. 

Salivation (sal-i-ve'shon). An excessive flow of the saliva. The word 
is practically synonymous with ptyalism, but, strictly speaking, de- 
scribes the condition when produced by the exhibition of medicines. 

Saturated Solution (satsh'iu-re-t^d). A solution which at a given 
temperature cannot contain more of the substance than it already 
contains. 

Scalpel (scal'pd). A small knife usually with a straight blade which is 
fixed firmly in the handle ; used in dissection and in surgical 
operations. 

Scapula (scap'iu-1^). The shoulder-blade. 

Scrotum (scro'tum). [Latin, "bag."] A pouch at the base of the penis 
in the male, containing the testicles and other organs. 

Sebaceous (si-be'shius). Fatty; suety; applied to glands which secrete 
an oily matter resembling suet. Resembling or pertaining to sebum 
or fat. 

Sebum (si'bum). A thick, semi-liquid substance discharged upon the 
surface of the skin, composed of fat and broken-down epithelial cells. 

Secretion (si-cri'shon). 1. A function of the body by which various 
fluids or substances are separated from the blood, differing in differ- 
ent organs according to their peculiar functions : thus, the liver 
secretes the bile, the salivary glands the saliva, etc. 2. The substance 
secreted. 

Secundines (stfc'un-dins). The after-birth; the placenta, etc., expelled 
after the birth of a child. (See Fig. 62.) 

Segmentation (s^g-m^n-te'shon). The process of division by which the 
fertilized ovum multiplies before differentiation into layers occurs. 
(Fig. 18.) 

Semen (si'm^n). 1. A seed. 2. The fluid secreted by the male repro- 
ductive organs. 

Septic (s^p'tic). Tending to putrefy; causing or due to putrefaction. 

Sepsis (sep'sis). 1. Putrefaction. 2. Infection and poisoning by putre- 
factive matter. 

Serous (si'rus). Of the nature of serum; secreting serum. 
S. Membrane. See under Membrane. 

Serum (si'rum). The clear, straw-colored liquid which separates, in the 
clotting of blood, from the clot and the corpuscles. 



GLOSSARY. . 445 

Shock (shoe). A condition of sudden depression of the whole of the 
functions of the body, due to powerful impressions upon the system 
by physical injury or mental emotion. The former is termed surgical 
and the latter mental shock. 
Show (sho). i. Popularly, the red-colored mucus discharged from the 
vagina shortly before child-birth ; called also " Labor-show." 2. 
The vaginal discharge in menstruation. 
Sims's Position (sim'ziz). [J. Marion Sims, noted American gynaecolo- 
gist, deceased.] That position of the patient in which she lies upon 
the left side and front of the left chest, with the right leg strongly 
flexed, or " drawn up :" called also Scmiprone position and Side 
position. (Fig. in.) 

S.'s Speculum, a vaginal speculum with duck-bill blades: by it 

the posterior wall of the vagina is held up, while the anterior 

is depressed, the patient being placed in Sims's position. 

(Fig. 114.) 

Skim Milk (scim). Milk from which the cream has been removed, 

leaving only one or two per cent, of fatty matter. 
Smegma (sm^g'maj. [From a Greek word meaning soap.] Sebum, 
especially the offensive, soap-like substance produced from the seba- 
ceous follicles around the glans penis and prepuce and in the region 
of the clitoris and labia minora. 

S. Embryo'num. Same as Vernix Caseosa. 

Solution (so-liu'shon). 1. The act of dissolving a solid body. 2. A 

clear, homogeneous liquid having particles of a solid, another liquid, 

or a gas uniformly diffused through it, so that the particles are 

invisible and do not separate upon standing. 

Sordes (sor'diz). Literally, "filth:" applied to the foul matter which 

collects on the teeth, particularly in certain low fevers. 
Sound (saund). [French, sonder, to fathom, to try the depth of the sea; 
hence, to try or examine.] An instrument for introduction through 
the urethra into the bladder, or into any canal. (See Fig. 118.) 
Specific (spi-stf'tc). 1. Relating to a species; distinguishing one species 
from another. 2. Suited for a particular purpose : as, a specific 
remedy. 3. Produced by a special cause. 4. A specific remedy; a 
remedy supposed to have a peculiar efficiency in the cure of a par- 
ticular disease, or one which has a special action on some particular 
organ. 

S. Disease, any disease produced by a special cause ; as syphilis 
and the eruptive fevers. (The term is frequently, but 
wrongly, restricted to syphilis.) 
S. Gravity, the weight of a body compared with that of another 
of equal volume taken as a standard : hydrogen is the 
standard for gases, and distilled water for liquids and solids. 




446 GLOSSARY. 

Spermatozoon (spcr"ma-to-zo'on). PI. spermatozoa. The motile micro- 
scopic sexual element of the male, resembling in shape an elongated 
tadpole. (Fig. 17.) The male element in fecundation. 

Sterile (st<?r'i'l). 1. Affected with sterility; barren. 2. Not containing 
micro-organisms ; aseptic. 

Sterility (stc-riYl-ti) . Inability, whether natural or as the result of 
disease, to procreate offspring. 

Sterilization (ster" i\-i-ze' shon) . The process of rendering an object 
sterile or free from micro-organisms or their germs. 

Sterilizer (stev'i\-a.i-zer). An apparatus for sterilizing objects. (Fig. 
18O 

Stillborn (stiTborn). Born without life; born dead. 

Stimulant (stim'iu-lant). 1. Stimulating. 2. A medicine having power 
to excite organic action or to increase the vital activity of an organ. 
A stimulant differs from a tonic in that its action is more speedy, 
more transitory, and usually followed by a reaction. 

Stimulate (sUm'iu-let). To excite the organic action of a part of the 
animal economy. 

Stimulus (stim'iu-lus). PI. stimuli. A Latin word signifying a 
" goad," " sting," or " whip." In physiology, that which rouses or 
excites the vital energies, whether of the whole system or of a part. 

Stool (stul). The faeces discharged from the bowels; a dejection; an 
evacuation. 

Streptococcus (str^p-to-coc'us). A variety of micro-organism. 

Stria (strai'%). PI. stria. A Latin word signifying a "groove," "fur- 
row," or " crease." 

S. Gravidarum, shining, whitish lines upon the abdomen caused 
by pregnancy or distention by abdominal tumors. (Fig. 30.) 

Stupor (stiu'por). A suspension or diminished activity of the mental 
faculties ; loss of sensibility. 

Styptic (sttp'tic). Having the power of stopping bleeding through an 
astringent quality; haemostatic. 

Subcutaneous (sub-ciu-te'ni-us). Situated just under the skin. 
S. Injection. See Hypodermic Injection. 

Suppository (su-poz'i-to-n). A preparation of some substance (usually 
cacao butter) fusible at the temperature of the body, and combined 
with some medicinal substance, for introduction into the rectum, 
vagina, urethra, or other cavity of the body. 

Suppuration (sup-iu-re'shon). The formation of pus or the processes 
giving rise to it. 

Suppurative (sup'iu-re-tiv). Producing or discharging pus. 

Suture (siu'tshur). 1. The junction of the bones of the cranium by a 
serrated line resembling the stitches of a seam. (Fig. 27.) 2. A 
stitch used to draw together the lips of a wound. 3. The thread or 
material used in making a stitch. 



GLOSSARY. 447 

Syphilis (sii'i-tis). A contagious venereal disease, communicable by 
contact of any abraded surface with the virus in coition or otherwise, 
and also by heredity and from the mother to a foetus. 

Symphyseotomy (sun"f»z-i-0t'o-rm). The operation of severing the 
ligaments and the fibro-cartilages of the pubic symphysis ; done in 
difficult labor. 

Symphysis (sim'ft-sts). The union of bones by means of an intervening 
substance; a variety of synarthrosis. 

S. Pubis, " symphysis of the pubis," the pubic articulation or 
union of the pubic bones which are connected with each 
other by interarticular cartilage. (Fig. i.) 

Synchondrosis (sm-con-dro'sts). A union of bones by intervening car- 
tilage; a variety of synarthrosis. See Articulation. 

Syncope (sm'co-pi). Literally a "cutting short" of one's strength; 
swooning or fainting; a suspension of respiration and the heart's 
action, complete or partial. 

T-Bandage. A bandage shaped like the letter T, — especially one in 
which the transverse limb passes around the body and the longitu- 
dinal one under the perineum. Used to hold dressings against the 
vulva. 

Tampon (tam'pon). i. A portion of gauze, sponge, etc., used in plugging 
a cavity or canal. 2. To apply a tampon to. 

Tamponade (tam-po-ned')- The use of the tampon or the act of using it. 

Tamponage (tam'pon-ej). See Tamponade. 

Tamponing (tam'pon-mg). The act of using a tampon. 

Tenaculum (ti-nac'iu-lum). A small hook-shaped instrument. 
T. Forceps, a volsella. 

Tenesmus (ti-nez'mus). A constant desire to go to stool or to urinate, 
with painful straining without the expulsion of faeces or urine. 

Testicle (tes'ti-c\). One of the two glands in the male contained in the 
scrotum. 

Thoracic (tho-ras'ic). Belonging to the thorax. 

Thorax (tho'nzcs). The chest, or that part of the body between the 
neck and the diaphragm and in the cavity of which are contained 
the heart and lungs. 

Thrombosis (throm-bo'sis). The formation or progress of a thrombus. 

Thrombotic (throm-bot'ic). Relating to or of the nature of thrombosis. 

Thrombus (throm'bus). A clot formed in any part of the circulatory 
apparatus. It differs from an embolus in that it is developed at the 
point where it is found, while an embolus is brought from a distance 
through the blood-vessels. 

Tissue (Ush'u). A web-like structure; a collection of cells or elements, 
of a constant structure and function, which go to make up the body. 
Examples : muscular tissue ; brain tissue ; bone tissue, etc. 



448 GLOSSARY. 

Torsion (tor'shon). A twisting. 

T. of the Umbilical Cord, the normal spontaneous twisting of 
the umbilical cord. 

Toxaemia (toc-si'mi-aj. Blood-poisoning. 

Toxemic (toc-si'rm'c). Relating to, or caused by, toxaemia. 

Traction (trac'shon). The act of drawing or pulling. 

Trendelenburg's Position or Posture (tr^n'd^-kn-burgz). That posi- 
tion in which the patient is placed flat on the back with body and 
thighs elevated to an angle of about forty-five degrees, the legs 
hanging over the edge of the table. It is used in abdominal surgery 
so that the abdominal viscera may be kept out of the way by gravi- 
tation. 

Tubercle (tiu'b^r-cl). A rounded eminence. 

Tuberculosis (tiu-b<?r-ciu-16'sis). A specific infectious disease due to 
the presence of the tubercle bacillus and affecting most often the 
respiratory and alimentary tracts, the peritoneum and parts of the 
brain. When the disease affects the lungs it is popularly known as 
" consumption." 

Tumor (tiu'mor). i. A swelling. 2. A morbid growth of new tissue in 
any part of the body, not due to inflammation, and differing in 
structure from the part in which it grows. Tumors may be solid 
or hollow (Cystic L). When a tumor tends to recur after removal, 
and infect the system, it is called Malignant; when it does not, 
Benign, Innocent, or Non-malignant. 

Tympanites (tim-pa-nai'tiz). Distention of the abdomen by gas in the 
intestines or in the peritoneal cavity; drum belly. 

Uterine T., distention of the uterus with gas; physometra. 

Typhoid State (tai'foid). A condition sometimes occurring in de- 
pressing diseases, in which there are great muscular weakness, brown 
tongue, muttering delirium, feeble pulse, and involuntary passage of 
urine and faeces. 

Ulcer (ul'ser). A loss of substance on some internal or external surface 

from gradual disintegration and destruction of the tissue. 
Ulcerate (ul's£-ret). 1. To form an ulcer in. 2. To become affected 

with ulcers. 
Umbilical (um-bfl't-cal). Pertaining to the umbilicus. 

U. Arteries, the arteries which accompany and form part of the 

umbilical cord. 
U. Cord [Latin, funis umbilicalis], the cord connecting the pla- 
centa with the umbilicus of the child, and at the close of 
gestation principally made up of the two umbilical arteries 
and the umbilical vein, encased in a mass of gelatinous tissue 
called " Wharton's jelly." 
U. Hernia, hernia at or near the umbilicus. 



GLOSSARY. 449 

Umbilicus (um-bi-lai'cus). The navel; the pit in the centre of the 

abdomen left by the shrinking of the umbilical cord. 
Uremia (iu-ri'mi-aj. The presence of urinary constituents in the blood, 
due to the suppression of the urine, and marked by headache, nausea, 
vertigo, eclampsia, and a peculiar odor of the skin. 
Uremic (iu-ri'rm'c). Relating to uraemia; affected with uraemia. 
Urea (iu'ri-3). The principal solid constituent of the urine. It is pro- 
duced by the decomposition of proteids and carries off most of the 
nitrogenous products of the body. Urea is also found in the blood 
and lymph. 
Urethra (iu-ri'thraj. The membranous canal forming a communication 
between the neck of the bladder and the external surface of the 
body. The female urethra does not exceed two inches in length, and 
the passage is considerably larger and more dilatable than that of 
the male. 
Urethral (iu-ri'thral). Belonging to the urethra. 
Urinal (iu'n'-nal). A vessel to receive urine. 
Urinalysis (iu-ri-nal'i-sts). Chemical analysis of the urine. 
Urinary (iu'n-ne-n). Relating to the urine. 
Urinate (iu'n-net). To pass urine from the bladder. 
Urination (iu-n-ne'shon). The act of passing urine. 
Urine (iu'rm). The saline secretion of the kidneys which flows from 
them through the ureters into the urinary bladder. 

Incontinence of U., inability to retain the urine in the bladder, 
so that it escapes without the knowledge or control of the 
patient. 
Retention of U., inability to pass the urine which accumulates 

in the bladder. 
Suppression of U., arrested secretion of urine from the kidneys. 
Urinometer, Urometer (iu-ri-nom'e-ter). An hydrometer for ascertain- 
ing the specific gravity of urine. 
Uterine (iu'te-n'n). Relating to the uterus. 

U. Appendages, the ovaries and Fallopian tubes. (Fig. 11.) 
U. Colic, paroxysms of pain in the uterus due to menstruation 

or to other causes, such as " false pains" or " after-pains." 
U. Gestation, normal pregnancy. 

U. Inertia, deficiency of contractile power of the uterus in labor. 
U. Involution, the process by which, after child-birth, the uterus 

reassumes its normal size and shape. 
U. Mole, a mass sometimes occurring in the uterus, consisting 

of a dead foetus which has undergone degeneration., 
U. Phlebitis, a form of puerperal fever. 

U. Pregnancy, normal pregnancy occurring in the uterus, as 
opposed to ectopic pregnancy. 
29 



450 GLOSSARY. 

U. Probe, a long, flexible probe for exploring the cavity of the 

uterus. (See Fig. 118.) 
U. Sinuses, cavities formed by the uterine veins in the walls 
of the uterus ; they are especially conspicuous in the preg- 
nant uterus. 
U. Sound, an instrument somewhat resembling a urethral sound, 
used in making examinations of the uterus ; a uterine probe. 
(Fig. n8.) 
U. Tubes, the Fallopian tubes. (Fig. n.) 

U. Wound, the area of the uterus from which the placenta has 
been detached. 
Uterus (iu'te-rus). The womb, a hollow muscular organ designed for 
the lodgement and nourishment of the foetus during its development 
until birth. (Figs. 9, 10, and 11.) 

Vagina (ve-jai'n^). [Latin, a sheath.] The curved canal, five or six 
inches in length, extending from the vulva to the uterus. (Fig. 9.) 
Vaginal (vaj't-nal). Belonging or relating to the vagina. 

V. Examination, examination of the vagina by introducing a 

finger. 
V. Speculum, an instrument for keeping open the vagina in 
order that its interior may be viewed. (Figs. 114 and 115.) 
Varicose (var't-cos). Unnaturally dilated; relating to a varix. 
Varicosity (var-i-cos'i-ti). 1. A varicose condition of the veins; vari- 

cosis. 2. A varicose vein ; a varix. 
Varix (ve'n'cs). A dilatation of a vein. 

Vascular (vas'ciu-l^r). Having, or relating to, vessels; full of blood- 
vessels. 
Vascularity (vas-ciu-lar'i-U). The state or property of being vascukr. 
Vectis (v^c'U's). The lever. In obstetrics, an instrument resembling 
one blade of an obstetrical forceps, for making traction upon the 
head of the fcetus in retarded labor. Seldom used and never seen 
now, as a single forceps blade answers the same purpose. 
Vein (ven). A tube conveying blood from the various tissues of th' 

body to the heart. 
Venous (vi'nus). Relating to the veins; contained in the veins. 

V. Blood, a dark-colored liquid collected in the veins from every 
part of the system. It is subsequently exposed to the in- 
fluence of the air in the lungs and is converted into bright 
red arterial blood. It contains more carbonic acid gas and 
less oxygen than arterial blood. 
V. Circulation, the circulation of the blood through the veins. 
V. Congestion, the engorgement of an organ with venous blood 
caused by interference with its return to the heart. 



GLOSSARY. 45 T 

Vernix Caseosa. " Cheesy Varnish." The layer of fatty matter which 
covers the skin of the foetus. 

Version (wr'shon). The act of turning; specifically, a turning of the 
child in the uterus so as to change the presenting part and bring it 
into more favorable position for delivery. (Figs. 75 and 76.) 

Vertebra (v£r'ti-braj. PI. vertebra. A peculiarly shaped bone, thirty- 
two of which compose the spine or vertebral column. 

Vertex (wr'tecs). The summit or top of anything. In anatomy, the top 
or crown of the head. 

V. Presentation, presentation of the vertex of the foetus in 
labor. (Fig. 43.) 

Vertigo (v^r'U-go). Dizziness; swimming of the head ; giddiness. 

Vesical (ves'i-cdl). Pertaining to the bladder; having the appearance 
of a bladder. 

Viability (vai-a-biYi-ti) . Ability to live. 

Viable (vai'a-bl). A term in medical jurisprudence signifying "able or 
likely to live :" applied to the condition of the child at birth. 

Virgin (wr'jm). A woman who has never had sexual intercourse. 

Virulent (vtr'iu-l^nt). Poisonous; malignant; caused by virus or 
having the nature of virus. 

Virus (vai'rus). Any poisonous matter produced by disease and capable 
of propagating that disease by inoculation ; a deleterious agent sup- 
posed to be a parasitic organism or germ. 

Viscus (vis'cus). PI. viscera. Any organ contained in the cavities of 
the body, especially within the abdomen. 

Visual (vizh'iu-al). Pertaining to, or used in, vision or sight. 

Vital (vai'tal). Belonging or essential to life. 

Vitality (vai-tal't-ti)- The principle of life. 

Volsella (vol-sd'aj. A forceps each blade of which has hooked ex- 
tremities; a volsellum. 

Vulsella, Vulsellum (vul-sd'a^ vul-sd'um). See Volsella. 

Vulva (vul'va). The external genitals of the female. (Fig. 8.) 

Walcher Position or Posture (val'cer or wal'tsh^r). That position 
of the patient in which she lies on her back with her buttocks 
raised and well over the edge of the table and her limbs hang- 
ing down as much as possible. (See Fi-g. 79.) In this position the 
true conjugate diameter of the pelvis is lengthened by nearly half 
an inch. 

Wet-Nurse. One who gives suck to the child of another. 

Wharton's Gelatin or Jelly (hwor'tonz). [Thomas Wharton, English 
anatomist, died 1673.] The jelly-like mucous tissue composing the 
bulk of the umbilical cord. 

Whites (hwaits). A popular name for Leucorrhcea, which see. 



452 GLOSSARY. 

Winckel's Disease (vtnc'flz). A very rare and extremely fatal disease 
of new-born infants, marked by icterus, hemorrhage, bloody urine, 
and cyanosis. Malignant jaundice. 

Witches' Milk (witsh'ez). A milky fluid secreted from the breast of 
the newly born. 

Womb (wum). The Uterus, which see. 



NDEX 



** 



Abdomen, pigmentation of, 72 

in pregnancy, changes in, 85, 
88 

size of, 88 

rupture into, 208 
Abdominal binder, 103, 121, 167, 
191. See also Binder 

pregnancy, 206, 207, 208 

pressure, 103, 190 

section, 255 

sponges, 233, 404 

supporter, 167 
Abnormity of child, 290 

of position, 158 
Abortion, 244, 245. See also Mis- 
carriage 

after-treatment of, 252 

a cause of, 374 

criminal, 252 

due to eruptive fever, 210 

due to syphilis, 212 

at four weeks, 55 

haemorrhage from, 204. 

induction of, 186, 193, 196 

legal, 252 

pain as symptom of, 205 

threatened, 246 
Abscess of breast, 279, 281 

from ectopic pregnancy, 208 
Accidental haemorrhage, 254 
Accidents of obstetrics, 253, 262, 

317 
Acini of breasts, 41 
Adhesive plaster, 191 
Adolescence, physical changes in, 
45 



Advice on care of infant, 304 
After-birth, 148, 152. See also 

Placenta 
After-care of mother, 163 

in symphyseotomy, 236, 237 
After-pains, 82 
Agalactia, .369 
Air-embolus, 164 
Air in the circulation, 272 

hunger, 205, 255 

passages, expansion of, 323, 
326 
Albumin, test for, 200 
Albuminuria, '73, 191, 196, 198, 200 
Alcohol disinfection, 364, 402 

dressings, 293 

effects of, upon germ plasm, 
no 

during pregnancy, no, 397 

rub, 170, 179, 193 
Alimentation, rectal, 185 
Aloes, 188 

Ammonia as antidote, 144 
Amnion, 51, 52, 53 
Amniotic sac, 52, 78, 151, 255 

rupture of, 78, 151, 255 
Amputation of uterus, 234 
Anaemia, acute, 205 

of pregnancy, 192 
Anaesthesia in bed, 246 

chloroform, 143 

at dressings, 287 

ether, 145, 146 

surgical, 141 

during version, 217 
Analgesia, 160 

453 



454 



INDEX. 



Analysis of urine, 113, 118, 196, 

198, 200, 202 
Anenometer, 351 
Animal food, 373 
Ankylosis, sacrococcygeal, 31 
Anointing baby, 292, 348, 354 
Anterior position of vertex, 95 
Antisepsis, 22, 401 
Antiseptic solutions, 138, 149, 401 
Antitoxin, tetanus, 345 
Anus, absence of, 343 

tearing of, 40 
Apncea, 323 
Appetite after labor, 83 

perverted, no 

during pregnancy, 71, 86 
Applicator, care of, 23 
Areola of breasts, 41, 69, 87 

pigmented, 42, 88 
Aristol powder, 171 
Arm in breech delivery, 158 

prolapse of, 99, 259, 260 
Arterial tension, 204 
Arteries, hypogastric, 64, 65 
Articulation of pelvis, 30 
Artificial food, 358, 376 
outfit for, 383 

respiration, Byrd's, 321, 326 
Sylvester's, 324, 325 
Ascites, 193 

Asepsis in obstetrics, 20, 22 
Asphyxia as cause of septic dis- 
ease, 340 

fatal, 271 

of infant, 161, 323 

livida, 317 

neonatorum, 317 

pallida, 317 

in protracted delivery, 259 

treatment of, 344 
Aspiration of mucus, 270, 320 
Aspirating needle, 270 
Ass's milk, 376 
Atelectasis, 344 



Atmosphere, moist, 300 
Auto-intoxication, 198 
Automobiling, 106 
Axis of child, 101 
Axis-traction forceps, 221, 223 
Ayres, Dr., bed devised by, 236 

Baby basket, 303 

extraction of, 229 

saving, 406 
" Baby-food babies," 376 
Baby's soap, 303 

Eacteria as cause of disease, 22, 
274, 277 

in cow's milk, 360 

in vagina, 21 
Bacillus tetani, 3 '4 
Bag of membranes, 51, 52 
Bags for dilation, 222 
Ballottement, 85, £9 
Baltimore, visiting nurses in, 410 
Barley-water, 385 
Barnes's bags, 222, 224 
Barrett, Dr., sponge technic of, 

404 
Bassinette, 127 
Bath before labor, 131 

thermometer, 308 
Bath-tub for baby, 306 
Bathing baby, 302 

of incubator baby, 355 

for mother, 107 
Bearing-down in labor, 78 

sensation, 136, 195, 196, 244 
Beaumes' law, 212 
Bed, change of, 165, 178 

coverings, 300 

double, 128 

for delivery, 128, 129 

for infant, 127, 300 

for symphyseotomy, 236 

metal, 128 
Bed-pan, use of, 83, 176 



INDEX. 



455 



Beer-bottles for hot water, 233, 

251, 265 
Beets, influence of, 370 
Belladonna to breasts, 371 
Bellevue Hospital School for 

Midwives, 19, 408 
Benzoinated lard, 348, 354 
Bichloride of mercury, 401, 402 
Bier congestion bell, 287 
Binder, abdominal, how to make, 
121 

advantage of, 164, 167 

applied after version, 216 

application of, 168 

for baby, 293 

maternity, 103, 285 
Binders and pads, soiled, 170 
Biniodide of mercury, 401, 402 
Bipolar version, 215 
Birth-marks, 115 
Birth- weight, 297, 298, 367 
Births, registration of, 410 
Bladder during labor, jj 

irritable, 76, 85, 191, 196, 207 
Blankets for baby, 315 
Bleeding from cervix, 264 

from cord, 349 

from retained placenta, 262 

in ectopic pregnancy, 208 

in feeble child, 154 

internal and fatal, 205, 254 
Blindness from albuminuria, 197 

from opthalmia, 339 

preventable, 335 
Bloating, 202 

Blondes, pigmentation in, 42, 88 
Blood in breast-milk, 374 

oozing of, 326 

state of, in pregnancy, 70 

sudden discharge of, 208 
Blood-clot after labor, 82 
Blood-current, fetal, 61, 64 
Blood-passages, fetal, 64 



Blood-poisoning from retained 

placenta, 245 
Blood-vessels, pulsation of, 139 
Blue babies, 343 
Body temperature,* 71 
Bone salt theory, 109 

surgery, 237 
Bones, wiring of, 236 
Bootees, 312 
Borax for mouth, 364 
Boric acid for eyes, 335 
Boston Lying-in-Hospital binder, 

285 
Bottle feeding, 360, 388 
Bougie, insertion of, 242 
Bowels after delivery, 175 
during labor, jj, 78 
regularity of, in, 306 
Box mattress, 128 
Brace for patient, 141 
Brain, anaemia of, 167 

vomiting centre in, 185 
Brassiere, 103 
Braun's hook, 239, 240, 241 
Braxton-Hicks method, 215 
Breast, abscess of, 279, 281 
child's refusal of, 366, 388 
congestion of, 283 
dawdling at, 366 
distention of, 283 
massage of, 280, 281 
milk, 360 

affected by grief, 375 
affected by worry, 373 
cream in, 371 
drugs excreted by, 392 
drying up, 392 
for infant, 113 
not digested, 369 
quality of, 369, 375 
quantity of, 369, 375 
Breast-binder, 285, 286 
application of, 365 
author's, 285 



45^ 



INDEX. 



Breast-binder, to dry up milk, 392 
Breast-feeding, 345, 370 

reflex action of, 81 
Breast-pump, 280, 355, 356, 358 
Breasts and uterus, sympathy be- 
tween, 40 

care of, 113, 361 

changes in, 69, 85, 87 

development of, 102 

diseases of, 274, 279 

enlarged, 283 

formation of, 41 

incision of, 287 

infection of, 23 

lactating, 369 

painful, 284 

pendulous, 103 

secretion of, 40 

shrinking of, 256 

soft, flabby, 361 

suppuration of, 287, 374 
Breech, delivery, 214, 217 
dangers of, 157 

presentation, 91, 96, 99, 155, 

157 
in twins, 159 
Brim of pelvis, 29 

measurement of, 33 
Brow presentation, 96, g8 
Brunettes, pigmentation in, 42, 73, 

88 
Brushes, tampica fibre, 134, 402 
Bubo, venereal, 211 
Buller shield, 337 
Bullet-forceps, 266 
Burning of discharges, 170, 213 

pads, 170 
Burns from external heat, 204, 

290 
Buttocks, elevation of, 186 
Cesarean section, 225, 228 

after rupture of uterus, 
258 



Caesarian section, different forms 
of, 234 
indication for, 228 
owing to deformity, 33 
preparations for, 228 
Caked breast, 281 
Calomel, dosage of, 346 
Cancer, curability of, 412 
of cervix, 228 
of uterus, 412 
Caput succedaneum, 332, 323 
Carbolic acid solution, 401 
Carbonic acid gas, elimination of. 

70 
Carpet, protection of, 231, 250 
Catharsis, saline, 285 
Cartilage, thickening and soften- 
ing of, 31, 73 
Cascara sagrada, 188 
Castor oil, 176, 188 
Casts in urine, 196 
Catching cold, 86 
Catheter, aspirating, 317, 320, 331 
feeding by, 358 
passage of, in symphyseotomy, 

236 
varieties of, 173, 250 
Catheterization, 172, 174, 264 

technic for, 403 
Cavity of cervix, 39 

of uterus, 38 
Cells, embryonic, 48 
Cephalhematoma, 334 
Cerebral anaemia, 167 
Certificate of birth, 410 
Certified milk, 377 
Cervix of uterus, 38, 39, 85 

dilation of, 52, 222, 243 
lacerations of, 81, 264 
ulcers of, 204 
Chafing, 297 

Champetier de Ribes bag, 222, 224 
Chancre, 211 
Change of life, 46 



INDEX. 



457 



Chapin dipper, 380, 382 
Chart records, 369 

temperature, 394 

weight, 309 
Cheese-cloth diapers, 312 
Chest walls, pressure on, 102 
Chicago Medical Society, 408 

midwives of, 408 
Child-birth, suffering of, 77 
Child-bed fever, 274 
Child forced to cry, 152 

viability of, 228, 244 
Children's Bureau, National, 304 
Chill after labor, 80 
Chilling the body, 104, 105, 106 
Chloasmata, 72 
Chlorine gas, 143 
Chloroform as cause of Winckle's 
disease, 340 

cough, 143 

dangers of, 144 

poisonous effects of, 144, 203 

use of, 141, 142, 143, 160 
Chorea in pregnancy, 195 
Chorion, 52, 53 
Circulation after birth, 61, 62, 65 

air in, 272 

defective, 343 

fetal, 53, 61, 63, 64, 65 

obstruction to, 104, 272, 277 
Citrate of magnesia, 175 
Cleaning up, 163 
Climacteric, 46 
Clitoris, 35 

adhesions of, 297 
Clot in heart, 262 

in veins, 277 
Clothing during pregnancy, 102 

for operations, 251 

of premature baby, 348 

outer, 104 
Coccyx, 28, 29 

Coffee, effects of, in lactation, 
370, 371 



Coffee, for nausea, 183 

Cold baths, 107 

Colic in infant, 180, 346 

cause of, 283 

cry of, 296 
Collapse in labor, 257, 269 
Colles' law, 212 
Cologne water, use of, 179 
Colon bacillus, 281 

irrigation, 346 
Colostrum, 70, 87, 113, 345 

crusts of, 280, 362 

disappearance of, 371 
Coma, eclamptic, 199 

in puerperal fever, 275 
Combined version, 215 
Comfort of mother, 178. 179 
Computation of date of labor, 90 
Concealed haemorrhage, 209, 254 
Conception, processes of, 48 
Condensed milk, 376 
Confinement in hospital, 120 
Congenital cyanosis, 343 

syphilis, 212 
Conjugate diameter, 218, 220 
Constipation after labor, 83 

in infants, $$$ 

in pregnancy, ill, 187, 191, 
196 

treatment of, 112 
Contagion, safeguards against, 

119 
Contraction of pelvis, 31, 33, 46 

of uterus, 163 
Control of sex, 115, 117 
Convulsions, causes of, 347 

eclamptic, no, 200 

epileptic, 200 

from haemorrhage, 262 

in renal colic, 346 

in spina bifida, 342 

of pregnancy, 197, 199 

of tetanus, 344 

puerperal, 262 



458 



INDEX. 



Cord, bleeding from, 148, 153, 272. 
326 

dressing, 23, 124, 293, 310 

ligatures, 395 

prolapse of, 138 

traction on, 152, 154, 156 

tying of, 148, 149, 152, 349 
Cornea, opacities of, 335 
Coronal suture, 59, 60 
Correspondence school graduate, 

19 
Corsets, 102, 190, 362 

maternity, 102, 103 
Cotton jacket, 355 
Cough in pregnancy, 194 
Coughing caused by chlorine gas, 

143 
Cow's milk, 358, 2,77, 39i 

chemical constituents of, 

378 
digestibility of, 378 
mixed, 378 
modified, 360 
reaction of, 381 
Crabs, 370 
Craniotomy, 237, 238 

intruments for, 239 
Cranium, passage of, at birth, 58 
Cream, centrifugal, 379, 380, 382 
gravity, 379, 380, 382 
tests, 373 
Crede's treatment, 133, 263, 264 
Crib for baby, 301 
Croquet, 106 
Crusts on nipples, 114 
Cry, characteristics, of labor, 78 
of child, first, 152 

significance of, 296 
Curettage after abortion, 246 
after infection, 276 
instruments for, 248, 249 
Cutting operations, 214, 224 
Cyanosis, 148, 199 
congenital, 343 



Cyanosis of eclampsia, 262 

Cyllin, 401 

Cyst, ovarian, 228 

Dammerschlaf, 160 

Dance, St. Vitus's, 195 

Dancing; 106 

Dangers of internal version, 217 

Death from chlorine gas, 143 

instant, from clot, 278 

of child, 284, 320 
Decapitation of foetus, 237, 238, 

240 
Decidua, basilis and capsularis, 50 

of menstruation, 49 

reflexa and vera, 50, 51, 52 

serotina, 50, 53 
Deformity of child, 115, 290 
from diaper, 306 
from dislocation, 329 

pelvic, 32, 242 
Delivery bag, 408, 409, 410, 411 

bed for, 128 

by nurse, 149 

hasty, 243 

instrumental, 31 217 

natural, impossibility of, 2^7 

operative, 209, 251 
Dental operations, 108 
Descent of head, 93 
Development of breasts, 362 

of nipple, 114 
Diabetes, 195 
Diagnosis, obstetrical, 100 

of pregnancy, 84, 85 
Diameter of pelvis, 30, 218, 220 
Diaper pin, 305 

red stain on, 296 
Diapers, 297, 304, 310, 312 

shaped, 305, 307 

used but once, 257 

washing of, 316 
Diarrhoea, 188, 345 

as cause of miscarriage, 112 



INDEX. 



459 



Diarrhoea of infants, 373 
Diet, 397 

during pregnancy, 109, 397 
puerperium, 179, 398 

farinaceous, 398 

kitchen, 377 

Prochownik's, 109, 400 

regulation of, in 

soft, 398 

starchy, for mother, 370 

vegetable, 373 
Digestion at birth, 297 
Digestive organs, tax upon, 70 
Dipper for top milk, 380 
Discharges, burning of, 170, 213 

during labor, 129 
Discipline, nursery, 295, 306 
Diseases, parasitic, 22 
Disinfection of room, 126 
Dislocations, 329 
Dispensary service, 407 
Displacement of uterus, 196 
Disposition during pregnancy, 86 
Distention of breasts, 284 
Dizziness in pregnancy, 197, 199, 

205 
Doctor's operating gown, 235 

table, 133 
Douche after miscarriage, 252 
for eye, 337 

infection from, 21, 22 

nozzle, danger in, 165 

solution for, 401, 402 

sterile, 131, 403 

tube, insertion of, 177, 178 

uterine, 267 

vaginal, 35, 176 
" Dragging " breasts, 365 
Drain for abscess, 287 
Dressing baby, 310 

on lap, 301, 336, 337 

forceps, use of, 140 

screen, 303 

table, infant's, 303 



Dressings, making of, 124 

Draw-sheet, 130, 166, 172 

Driving, 106 

Dropsy, 193 

Drugs excreted by the milk, 3Q2 

Dry labor, 242 

Ductus arteriosus, 64, 65 

venosus, 64, 65 
Duration of labor, 79 
Dusting powder for baby, 297 
Dyspnoea in infants, 344 
Dyspnoea of pregnancy, 188 

Ears, ringing in, 197, 205 

washing of, 308 
Eclampsia, 197, 222, 253, 256 

convulsions of, 199 

forerunner of, 187, 191 

in puerperium, 262 
Eclamptic toxaemia, no 
Economy in home accouchement 
24, 124, 126 

in washing, 310 
Ectopic gestation, 204, 205, 206 
rupture of sac in, 255 
Eczema intertrigo, 297 

of face, 193 

of nipple, 287 
Efficiency of nurse. 25 
Eight-months baby, 75 
Eight per cent, milk, 378, 382, 384 
Electricity, 370 
Elliott's forceps, 222 
Embryo, growth of, 50, 55, 56 
Embolism, 271 
Embryotomy, 237 
Emergencies. 153, 253 
Emergency dressings, 23 
Emerson, Dr. Haven, 20 
Emetics, self-administered, 186 
Emotional phenomena, 74, 85 
Enamel cloth, 122 
Enemata during labor, 151 

nutrient, 185, 399 



460 



INDEX. 



Enemata soapsuds, 131, 176 
English breast-pump, 356 
Engorged blood-vessels, 283, 284 
Epidemic tetanus, 345 
Epilepsy, 200 
Episiotomy, 237 
Ergot, 162, 267, 395 

" poor woman's," 188 
Eruptive fevers, 210, 213 
Esmarch apparatus, 142, 148 
Ether anaesthesia, 141, 145. 160 
danger signals in, 148 

for convulsions, 203 

irritating action of, 145 

cone, 145 
Evisceration, 237, 240 
Excretory organs, testing of, 70 
Exercise, 105, 106, 192 
Exostoses, 29 
Expiration, artificial, 323 
Exposure of patient, 122, 140 
Expulsive forces of labor, 91 
Extension of arms, 157 

process of, 94 
External os, 39 

rotation, 94 
Extremity, prolapse of, 259 
Ewald's enema, 399 
Eyebrows and eyelashes, 58 
Eyes of infant, care of, 140, 149, 
290, 299, 308 

infection of, 213, 334, 337 

Face, cyanotic, 139 

pigmentation of, 72 

presentation, 95, 96, 98 

guard, 394 
Facial paralysis, 333 
Fainting, 192, 194 
Fallopian tubes, 35, 37, 39- A3 
impregnation in, 206 
False pains, 135 
Fat babies, 376 

in milk, 372, 378 



Fat of baby, 298 

Fear of operation table, 247 

Feather bed, 127 

Feeder for feeble baby, 357 

Feeding hours, 364, 368, 375, 383 

mixed, 374 

rectal, 185 
Feeding-tube, glass, 395 
Feminist movement, 24 
Fermentation of milk. 389 
Fetal circulation, 53, 61 

development, 48, 55, 58 

in multiple conceptions, 
66 

ducts, shrivelling of, 65 

heart sounds, 90 

cessation of, 256 

movements, 89 

structures, 61 
Fever, cause of, 179 

eruptive, 210 

high, a cause of miscarriage, 
244, 255 

milk, 83 

puerperal, 275, 276 
Fibro-cartilage, pelvic, 31 
Figure, preservation of, 167 
Figure-of-eight ligature, 273, 329 
Finklestein's feeding. 391 
First stage of labor, 76, 77, 131 
Fissure of nipple, 114, 279, 282, 

283 
Flabby uterus, 162 
Flattening of belly, 88 
Flesh, increase in, 71 
Flexion of head, 93 
Flooding, treatment of. 265, 267 
Flowers in room, 180 
Flushing the system, 201 
Foetus, death of, 84, go, 159. 256 

diseases which affect, 213 

formation of, 48 

mummified, 208 



INDEX. 



461 



Foetus nourishment of, 51, 52, 61, 
64, 70 
oxygenation of blood of, 52, 

61, 64 
passage of, through pelvis, 31, 

39 
position of, in uterus, 60 
removed by abdominal sec- 
tion, 206 
retained in belly, 208 

Fontanelles of cranium, 58, 59, 60 

Food as preventive of nausea, 183 
cravings, 86, 87, no 
during pregnancy, 109 
for premature baby, 355 

Foot presentation, 100 

Foramen ovale, closure of, 64, 65 

Forceps, care of, 23 

cephalhematoma from, 334 
delivery, 31, 217, 332 
for dressings, 337 
types of, 220 

Foreskin, adherent, 296 

Formalin, 402 

Formulas for milk, 379, 381, 383 

Fornices, 38 

Fourchette, 35 

Four per cent, milk, 379 

Fractures of the new-born, 329 

France, legitimacy in, 75 

Freeman pasteurizer, 390 

Fresh air for infant, 127 

Fright, 244, 373 

Frontal bone, 58 

Fruit diet, 109 

Fruits as cause of colic, 180 

Fundus, care of, 152, 156, 158, 
162, 203, 265 

Funis, 53 

Gait in pregnancy, 73 
Galactorrhea, 370 
Galbiati knife, 236 
Gall-duct, affection of, 311 



Garters, 104, 190 
Gas and oil heaters, 300 
Gauze packing, 231 
expulsion of, 269 
sponge technic, 404 
Genital canal, blood-supply of, 69 
organs, changes in, 69 

of foetus, 55 
tract, infection of, 274 
Genitalia, scalding of, 297 
Genitals, external, cleansing of, 
137, 165, 170, 251, 403 
swelling of, 70 
Gestation, duration of, 75 

multiple, 65 
Gigli wire saw, 237 
Glands of Montgomery, 69 
Glans penis, care of, 296 
Glass catheter, 173 
Gloves, rubber, necessity of, 21 

sterilization of, 23, 134, 
139. ISO 
Glucose enema, 399 
in urine, 73 
Goat's milk, 376 
Golf, 106 
Gonorrhoea, as cause of sterility, 

213 
Gonorrhceal infection of eyes, 335 
Gooch, Dr., views on flooding, 265 
Goodell uterine dilator, 247 
Gossip, 25, 180 
Gout, a cause of pruritis, 195 
Gown, operating for nurse, 150 

393, 394 

protective, 139, 150, 213, 287 
Graafian follicle, 43, 48 
" Granny " knot, 153 
Grape-sugar enema, 399 
Green stools, 296, 345 
Grief, 244 

effect of, on milk, 375 
Groin, pain in, 278 
Guaranteed milk, 377 



462 



INDEX. 



Gumma, 211 
Gynaecological cases, 25, 27 

Habits, formation of, 295 
Hair bed, 127 

care of, 131, 137, 178 

improved growth of, 71 

pubic, clipping of, 45, 130, 
137, 165, i/7, 228 
Hammock, canvas, 236 

for infant, 395 
Handling of infant, 301 
Hands, disinfection of, 23, 134, 
139, 170, 401 

infection from, 21 
Head, delivery of, 79, 94, 151 

descent of, 138, 150 

injuries, 329 

of foetus, 58 

prolonged pressure on, 332 
Headache in pregnancy, 194 
Heart, blood-clot in, 262, 271, 278 

diseases of, 192 

failure, 259 

foetal, 90 

hypertrophy of, 102 

palpitation of, 72 

sounds, foetal, 85 
Heating of incubator, 349, 351 
Hebsoteotomy, 237 
Heels, high, injurious effects of, 
105 ' 

holding by, 320 
Hegar's sign, 85 
Haemorrhage, concealed, 81, 205 
Haemorrhage, control of, 266 

during labor, 256, 257 

during pregnancy, 204, 253 

during puerperium, 262 

from cord, 148, 153, 326 

from stomach, 210 

from vagina, 208 

pallor from, 205 



Haemorrhage, post-partum, 152, 
162, 167, 203, 240 

secondary, 272 
Haemorrhagic diathesis, 326 
Haemorrhoids, 176, 191 
Heredity as cause of insanity, 288 

twins, 65 
Hereditary traits, 116 
Hernia, umbilical, 342 
High operation, 221 
Hippocratic oath, 213 
Hirschsprung's disease, 343 
Holt's apparatus, 371 
Holmes, Oliver Wendell, 277 
Home accouchement, 120 
Horseback riding, 106 
Hospital, delivery in, 120, 137, 233 

equipment, 404 

incubators, 349, 351 

maternity, 126 

treatment for vomiting, 185 
Hot applications, 337 

bath for convulsions, 346 

pack, 203, 208 
Hot-water bottles, 233, 251, 265. 

349 
for constipation, 187 
immersion, 320 
Hull House, 408 
Hunger of baby, 368, 369 
Hunyadi water, 188 
Hygiene for nurse, 119 
of baby, 299 
of pregnancy, 102, 118 
of the eye, 299 
personal, 24, 11 1, 187 
preventive, 201 
Hyperemesis gravidarum, 186, 
400. See also Pernicious Vomit- 
ing 
Hypodermic case, 395 
Hypodermoclysis, 203, 233, 271. 
400 



INDEX. 



463 



Hysteria, convulsions of, 201 
during labor, 288 

Ice-bag to breasts, 285 
Ice compresses, 336, 340 

pads, 337 

rub, 267 

to eyes, 335 

water immersion, 320 
Iceland moss, 174 
Icterus neonatorum, 311 
Ilium, 28, 29 
Illegitimacy as cause of insanity, 

288 
Immunity, natural, 21 
Impregnation of ovum, 39, 44 
Inability to nurse, 367 

to walk, 236 
Incubator, 348, 351 

ambulance, 349 

baby, cry of, 354 
weight of, 35s 

ventilation of, 351, 353 
Indigestion, cause of, 179 

in pregnancy, 197 

of infants, 373 
Induration of breast, 281 
Infant, care of, 290, 304 

clothing, ideal, 313, 314 

early training of, 295, 306 

feeding, 360 

regulation of, 359 

inspection of, 149 

mortality, 405 

pre-natal care of, 304 

separate room for, 180 

Welfare Societies, 391, 405 
Infants' crib, 300 

mouth, care of, 364 

underwear, 311 
Infants, vaginal discharge in, 342 
Infection, genital, in baby, 297 

modes of conveying, 21 

of breast, 284 



Infection of eye, 335 

of syphilis, 211 

precautions against, 119, 150, 
177 

puerperal, 20,. 274 

septic, 22 
Infusion apparatus, 24, 271 

subcutaneous, 269 
Inhaler, ether, 145 
Injection, intravenous, 203 
Injury of child, 290, 329 
Innominate bones, 28 
Insane, care of, 289 
Insanity, maniacal, 288 

of pregnancy, 74, 287, 288 

of unmarried mother, 288 

puerperal, 274 
Insomnia, 193 

Inspection of placenta, 155 
Inspiration, artificial, 323 
Instrumental delivery, 214 

for craniotomy, 238, 239 

for curettage, 247, 248 

infection from, 21, 22 

use of, 135, 140 
Internal os, 39 
Intestinal colic, 346 
Inunctious, olive oil, 400 
Invalidism as result of infection 
22, 274 

pregnancy, 27 
Inversion of uterus, 154, 257 
Involution, process of, 81, 82, 181 
Irrigator, 24, 131, 166, 176, 250 
Irrigation of eye, 337, 338 
Ischium, 28, 29 
Isolation for eye disease, 339 

Jacobi, Dr. Abraham, 407 
Jaundice, cause of, 144 

of new-born, 311, 340 
Jenness-Miller corset, 102 

Kelly pad, 132, 140, 166 

improvised, 221, 337 



464 



INDEX. 



Kicking of foetus, 90 
Kidneys, action of, 107 

care of, 112 

disease of, 73, 198 
Kneading of uterus, 163 
Knee-chest position, 261 
Knot, square, 153 
" Krause " method, 242 

Labia, majora and minora, 34, 35 
Labor bed, 127, 128, 129 

beginning of, 136 

cause of, 76 

date of, 90 

duration of, 79 

forces of, 91 

induction of, 242 

mechanism of, 91 

pains, 77, 82, 131, 136 

phenomena of, 75 

premature, 76 

premonitory symptoms of, 76 

preparations for, 118 

room, care of, 149, 150 
furnishing of, 133 

scientific supervision of, 26, 
27 

stages of, 76 

sudden death in, 257 

supplies needed for, 121 

unassisted, 135 
Laborde's tongue traction, 326 
Laceration of tissues, 91, 150 

in first labor, 67 
Lacing during pregnancy, 103 
Lactation as cause of fever, 83 

affected by menstruation, 373 

function of, 102 

insanity of, 288 

mastitis in, 284 
Lactose in milk, 371 
Lamboidal suture, 59, 60 
Lap, bathing upon, 292 



Lap, for dressing baby, 301, 336, 

337 
Laparotomy sheet, 404 
Larynx, irritation of, 143 
Lavage for vomiting, 186 
Laxatives, mild, 175, 188 
Layette for baby, 299, 311 
Lead poisoning, 213 
Leg, bandaging of, 269 

clot in, 277 

enlargement of, 2/8 

holder, 236, 246, 247, 251 

prolapse of, 259, 260 

stiffness of, 278 
Legal abortion, 252 
Legislation concerning pregnancy, 

75 
Leube's test meal, 400 
Leucorrhcea, 194 
Ligaments of uterus, 36 
Ligature, figure-of-eight, 273 
Light diet, 179 
Light for operation, 250 

in incubator, 355 
Lime water, 381 
Linea albicantes, 67, 68 
Liquid diet, 398 
Liquor amnii, 51, 52 
Lists for obstetrical nurse, 23 
Liver, effect of chloroform upon. 
144 

in newborn child, 64 

toxaemia of, 203 
Lividity of child, 317 
Living child, sacrifice of, 238 
Lithotomy position, 217, 219, 236 
L. O. A. position, 93 
Lobules of breasts, 41 
Local anaesthesia, 287 
Lochia cruenta, 82 

infection from, 172, 2Sr 

in puerperal sepsis, 275 

odor of, T76, 179 

purulenta. 82 



INDEX. 



465 



Lochia rubra and sanguinolenta, 

82 
"Locked" twins, 157, 159 
Lockjaw, 344. See also Tetanus 
London, overlain babies in, 345 
Longings, morbid, 85 
Lubrication, 23, 69, 174, 280 
Lubrichondrin, 139, 140, 261 
Lungs, hemorrhage from, 210 

inflation of, 323, 326 

pressure upon, 70 
Lying-in hospital, 407 

room, choice of, 125 
disinfection of, 126 

state, 80 
Lysol solution, 23, 132, 401 

Malaria, a cause of abortion, 211 

213 
Male germ, impregnation by, 39, 
44, 206 
pelvis, 31 
Malformation of rectum, 343 
Malposition of foetus, 222, 228 

dangers of, 259 
Mammae, 40. See also Mammary 

Glands and Breasts 
Mammary glands, 40 
Minia during labor, 288 
Manipulation of baby, 354 

of foetus, 214 
Marriage of syphilitics, 212 
" Marked " children, 115 
Marshall Hall artificial respira- 
tion, 323 
Mask for doctor and nurse, 235 
" Masque des f emmes enceintes, 

72 
Massage for insomnia, 193 
in pregnancy, 106 
in puerperium, 182 
of breast, 280, 281, 356, 370, 392 
Mastitis, 283, 284 
chills in, 285 



Mastitis, in infants, 342 

suppurative, 287 

surgical treatment of, 287 
Maternal impressions, -115 
Maternity hospitals, 349 
Mattress for infant, 300 

for labor bed, 129 
Meat in dietary, 179 
Meatus urinarius, 35 
Meconium, disappearance of, 298 

passage of, from vagina, 97, 
156 
Melancholia in pregnancy, 74, 287, 

288 
Membranes, expulsion of, 79, 151 
Membranes, retained, 252 

rupture of, 138 
Meningitis, traumatic, 332 
Menopause, 46. See also Change 
of Life, Climacteric 

pregnancy preceding, 47 
Menstruation, 45, 46 

cessation of, 410 

changes in uterus during, 49 

in ectopic pregnancy, 207 

in nursing mother, 373 

its relation to ovulation, 45 

suppression of, 85, 86 
Mental balance during adolescence. 
45 

phenomena, 85, 86 

state, 345 
Metabolism of labor, 340 
Midwife as nurse, 406 
Midwifery in New York City, 2c 

in United States, 19 
Midwives, attendance of, 407 

registration of, 407 
Milk, affected by fright, 373 

ass's and goat's, 376 

chemical constituents of, 371 

contamination of, 358 

diet, 398 

ducts, 42 



466 



INDEX. 



Milk, eight per cent., 378, 382, 384 

expression of, 280, 284, 355 

fever, 83 

formulas, 379 

four per cent., 379 

leg, 274, 278 

over-secretion of, 280, 283, 370 

pasteurized, 389 

secretion of, 40, 370 

solids in, 371 

stations, 377, 407 

sterilized, 389 

sugar, 362, 381 

supply in cities, 377, 388 

true, appearance of, 362, 365 

twelve per cent., 378, 380, 384 
Miscarriage, 106, 108, 112, 195, 244 

after-treatment of, 252 

causes of, 255 

dangers of, 246 

first symptom of, 256 

from albuminuria, 198 

from diarrhoea, 188 

precautions during, 245 

prompt action in, 253 
Mitral valve, 192 
Mixed feeding, 361, 375 
Modified milk, 376 

apparatus for, 384 

how secured, 377 
Moisture in air, 353 
Monstrosity, 228 
Mons Veneris, 34, 72 
Montgomery gland, suppurating, 

69, 87, 284 
" Morning sickness," 75, 85, 86, 207 
nervous origin of, 185 
prevention of, 183 
Morphine, effects of, 116 

in obstetrics, 160 
Mortality from concurrent dis- 
eases, 210, 211 

from eclampsia, 198 

from sepsis, 277 



Mortality, puerperal, 20, 22 
Mother's bed, 127 

milk, composition of, 371 
drugs excreted by, 392 
quality of, 371 
substitute for, 358 
value of, 370 
outfit, 121 
Mothers, education of, 406 

unmarried, insanity of, 288 
Moulding of infant's head, 60 
Mouth, care of, 149, 151, 308 
Mucous patches, 211, 212 

surfaces, destruction of, 399 
Mucus in throat, 317, 318, 320, 331 
Multigravida, 68 

Multiparas, impaired health of, 288 
Multiple conceptions, 65, 66 

foetal development in, 66 
Murder, tendency to, 288 
Murmur, uterine, 85 
Murphy saline drip, 269 
Mutilation of foetus, 214 

Nail-bursh, 121 

Nasal feeding, 399 

National Children's Bureau, 304 

Nausea during labor, 77, 78 

in pregnancy, 70, 86, 183 
Navel, 53. See also Umbilicus 

bleeding from, 272 

infected, 311 
Neck injuries, 399 

of foetus, broken, 240 
Nephritis, latent, 74 
Nerve impulses, 117 
Nervous shock, 244 

effects of, 373 

system, disturbance of, 74, 114 
Neuralgia, 194 
Neurotics, feeding of, 399 
^New-born infant, 290 

asphyxia of, 317 
injuries of. 32$ 



INDEX. 



467 



New-born infant, septic disease 

of, 340 
New York City, milk supply in, 

377 

statistics of obstetrics in, 
20 
Night-gown, changing of, 164 
Nipple, 42 

for bottle, 386 

injured by infant, 284 

precautions concerning, 282 

shield, 282, 359 
Nipples, anointing of, 361 

care of, 24, 113 

cracked or fissured, 114, 279, 
282 

diseases of, 274, 279 

pigmentation about, 72 

soreness of, 181 

syphilitic, 287 
Nitrate of silver, 292 
Normal infant, 290 

labor, 135 
Nose-bleed, 210 
Nostrils, care of, 303, 308 
Nourishment of infant, 102 
Nurse as anaesthetist, 144, 148 

delivery by, 149, 150 

disinfection of, 119 

disqualification of, 119 

duty of, 84, 119 

efficiency and personality of, 
25, 118, 159 

engagement of, 120 

infected by infant, 212 

neglect on part of, 268, 276 

obstetrical diagnosis by, 100 

opinions of, 161, 252 

pay of, 119 

visiting, 406 
Nurse's aprons and dresses, 393 

bag, 268 

gown, 235 

obstetrical outfit, 393 



Nurses' Directories, 119 
Nursery bath-room, 304 

ideal, 299, 301, 304 
Nursing bottles, care of, 358, 385, 
387, 388 ' 

dawdling in, 388 

in twilight sleep, 161 

obstetrical, 22, 27 

private, 24 

regularity in, 362 
Nut-gall ointment, 191 
Nutrient enemata, 399 

Oatmeal-water, 385, 386 

" Obstetrical camp-follower," 25 

cases, agencies for care of, 19 

nursing, ideals of, 404, 409 
outfit for, 393 

service, voluntary, 407 

suit, 122 

surgery, 233 

training, 407 
Occipital bone, 58 
Occiput, rotation of, 93 
Oedema during pregnancy, 113 

general, 197, 200, 202 

of extremities, 70, 191, 192 
Olive oil inunctions, 348, 400 
Operating cap; 394 
Operation, preparations for, 228 
Operations at home, 24 

non-cutting, 214 
Operative delivery, 91, 95, 214, 260 
Operculum, 21 
Opisthotonos, 344 
Ophthalmia neonatorum, 334, 336 

in New York City, 20 
Opinions of nurse, 161, 252 
Organs of generation, 34, 35 
Osmosis, 53, 70 
Ossification of fontanelles, 60 
Osteomalacia, 32 
Os uteri, dilatation of, 78, 139 
Outdoor life for baby, 311 



4 68 



INDEX. 



Outfit for infant and mother, 121 
Ova, transplantation of, 117 
Ovarian cyst, 22S 
Ovaries, 35, 37, 39 

contents of, at birth, 43 
Over-feeding, 179 
Overgrowth of fcetus, 222, 228 
Overlaying of infant, 345 
Ovulation, process of, 39, 43, 44 
Ovum, impregnation of, 39, 44, 48. 
206 

in abdomen, 206 

segmentation of, 49 
Oxalic acid, 402 
Oxygen, fcetal intake of, 116 

in convulsions, 203 

inhalations of, 344 

supply of, 102 
Oxygenation of blood, 52, 61, 64, 
70 

Packing of uterus, 258, 268 

Pads, intestinal, 229, 231 
laparotomy, 404 
obstetrical, 121, 130, 165, 166 
vulva, 23, 133, 137, 170 

Pain accompanying hemorrhage, 

254 

as symptoms of abortion, 205 
during suckling, 280 
excruciating, 208, 209, 255 
in ectopic pregnancy, 207 
menstrual, 45, 46, 373 
Pains of labor, 77, 138 
relief of, 160 
shooting, in breasts, 85 
Pajamas. 122, 137 
Pallor after delivery, 162 

sudden, 142 
Palpation of abdomen, 100 

of the heart, 72 
Paper bags, 302, 309 
Paralysis in pregnancy, 194 
of infant, facial, 333 



Paraphimosis, 296 

Parietal bones, 58 

Parturition, 75 

Passive movements, 106, 182 

Pasteur, views of, 22 

Pasteurization, 389 

Patent baby foods, 376 

Pathology of pregnancy, 183 

Pawlik's grip, 101 

Payment of nurse, 120 

Pelvic disorders, cause of, 25, 26 

palpation, 101 
Pelvimeter, 32 
Pelvis, anatomy of, 28 

contracted, 75, 222 

deformity of, 228, 242 

female, compared with male, 
3i 

inclined planes of, 93 

inlet of, 30 

measurement of, 32, 33 

sensation of weight in, 46 

tilting of, 218, 220 
Pendulous breasts. 103 
Perineal pad, 122, 165. 167 
Perineum, care of, 150 

torn, 40, 171 
Peritonitis, puerperal, 208, 213 
Permanganate of potassium, 401 
Pernicious vomiting, 184, 186 
Perspiration, 104, 197 

excessive, 178 

during labor, 80 
Phimosis, 296 

Phlegmasia alba dolens, 274, 277 
See also Milk Leg 

treatment of. 278 
Physical development, faulty, 33 

retardation of, 27 
Physiology of pregnancy, 67 

of puerperium, 80 
Pigmentation, general, 72 

of abdomen, 68, 88 

of breasts, 42, 85 



INDEX. 



469 



Pillow for baby, 301 
Pins, discarding of, 305, 307, 315 
Pin-sticking, 305 
Placenta, as part of mother, 116 
delivery of, 21, 79, 148, 152, 

154 
detachment of, 204, 210, 254 
examination of, 148, 155 
formation of, 51, 53 
manual extraction of, 263 
maternal surface of, 54 
prsevia a cause of bleeding, 
204, 253 

forms of, 208 
retained, 245, 252, 262 
site of, 44 
Playing with baby, 295, 368 
Pneumonia in pregnancy, 210 
Poisons, care of, 402 
excretion of, 203 
Pole of fcetus, 101 
Poor mother, care of, 405 
Position of foetus, 91, 93 
Post-mortem Caesarean section, 234 
Post-partum haemorrhage, 162, 265 
emergency treatment of, 
270 
Poverty, nursing amidst, 405 
Powder for baby, 171, 293 
Precipitate delivery, 157 

labor, 139, 149, 154, 157, 260 
Pregnancy, abdominal changes in, 
88 
before menstruation, 45 
care of breasts in, 361 
convulsions in, 197 
decidua of, 49 
diseases complicating, 205 
disorders of, 183 
duration of, 75 
during lactation, 374 
emotional changes in, 74 
extra-uterine, 206 
extreme limit of, 75 



Pregnancy, interstitial, 206 

management of, 102, 202 

physiology of, 67 

prevention of, 226 

requirements of, 26 

sign of, 42, 69, 84, 85, 88 

supervision during, 26 

symptoms of, 84, 85 

systemic changes in, 70 

tubal, 206 

urinary analyses in, 118, 196, 
198, 200, 202 

urine of, 73, 118, 196, 198, 200, 
202 

walking during, 105 
Premature baby, 348 
breast-fed, 355 
feeding of, 357 
temperature for, 349 

birth, 154, 155 

infants afterward famous, 359 

labor, 244 

labor, causes of, 244 

induction of, 75, 242 
management of, 252 
Prenatal care, 20, 25, 304 
Presentation, abnormal, 100, 158 

of fcetus, 91 
Preservation of milk, 391 
Pressure, injury from, 103 

uterine, in 
Prevention of waste, 19 
Preventive medicine, 27 
Primigravidse, care of, 26 
Prochownik's diet, 109, 400 
Prolapse of cord, 259, 260 
Promontory of sacrum, 29, 30, 33 
Proteids in milk, 371, 372, 373, 378 
Protracted labor, 78 
Pruritis, 195 

Psychical development, 45 
Psychology, nurse's knowledge of, 

25 
Ptyalism, 193 



4/0 



INDEX. 



Puberty, 45 

Pubiotomy, lateral, 237 

Pubis, 2S, 29, 30 

Public Healtb Nurse, 377, 406 

Puerperal fever, 274 

insanity, 287 

sepsis, 20, 21, 274 

mortality from, 20, 22, 277 

state, 80 
Puerperium, diet during, 398 

duration of, 181 

emergencies in, 262 

management of, 162 

pathology of, 274 
Pulmotor, 326 
Pulse after labor, 80 

irregularity of, 142 

of infant, 294 

record of, 177 
Purpura, 329 
Pus cases, nursing of, 119 

in breast milk, 374 

in eyes, 337 
Pyogenic organisms, 22 

Quadruplets, 65, 66 
Quickening, 85 
Quiet for baby, 299, 368 
Quinine as cause of abortion, 211 

Rabbits, impregnation of, 117 
Records, keeping of, 133, 395 
Rectal irrigation, 269 

medication, 185 

tenesmus, 191 

tube, rubber, 176 
Rectum, impacted, 343 
Red Cross nurse, rural, 19, 406 

visiting, 407 
Registration of births, 410 

of midwives, 407 
Regurgitation of food, 367 
Reigel's test meal, 400 
Resistant forces of labor, 91 



Respiration, artificial, 320, 326 

before delivery, 157 

establishment of, 61 

failure of, 142 

in convulsions, 199 

interference with, 103 

stimulation of, 318, 319, 320 

under anaesthesia, 147 
Responsibility of nurse, 24, 26 
Rest during menstruation, 45 

for feeble baby, 354 
Restitution of position, 94 
Resuscitation of child, 317, 320 
Byrd's method, 321, 322 
Sylvester's method, 327 
Rickets, 109 
Robb's leg-holder, 247 
Rochelle salt catharsis, 197 
Room, incubating, 349, 351 

lying-in, 125, 126 

separate, for baby, 295, 345 
Rotation of head, 94 
Rubber apron, 393 

bag, objections to, 131 

gloves, 23, 134, 139, 150, 171, 
213, 394, 402 

sterilization of, 23, 134, 
139, 150 

nipples, care of, 386, 387 

sheeting, 122, 129, 300 
Rupture at umbilicus, 342 

of uterus, 257 

symptoms of, 210 
Rural nursing, 100, 148, 406, 407 

Sac, amniotic, rupture of, 78, 151, 

255 
Sacro-coccygeal articulation, 30 
Sacro-iliac synchondroses, 30, 31 
Sacrum, 28, 29 

Safety-pins, swallowing of, 305 
Sagittal suture, 59, 60 
St. Anthony's dance, 195 
St. John's dance, 195 



INDEX. 



471 



St. Vitus's dance, 195 
Saline douche, 267 

enema, 399 

infusion, 232 
Saliva, secretion of, 193 
Salivation, 193 
Salt solution, normal, 177, 401 

water bathing, 107 
Salvarsan treatment, 212 
Scalding milk, 389 
Scales for infant, 309, 395 
Scalp, care of, 311 

swelling of, 332, 333 
Scarlet fever, 210 
Scars, 329 

Schroeder's retractor, 248 
Schultze swinging method, 326, 

328, 330 
Scopolamine in obstetrics, 160 
Screen for baby, 303 
Scrub-up technic, 134, 402 
Sea sponges, 303 
Seborrhcea capitis, 311 
Second stage of labor, 76, 78, 138, 
141 

pain in, 138 
Secondary haemorrhage, 273, 326 
Secretion of milk, cessation of, 

279 
Secretory organs, tax upon, 70 
Sedatives, effect of, 204 
Segmentation of ovum, 49 
Self-control, 115 
Semmelweiss, 277 
Sensation of weight in pelvis, 46 
Sepsis, 22 

constitutional effects of, 276 

in hospitals, 277 
Septicaemia, puerperal, 20, 21, 274 
Serum injections, 213 
Seven-months baby, 75 
Sewer-gas poisoning, 213 
Sewing-machine, use of, 107 
Sex, control of, 115, 117 



Sex control of twins, 65 

recognition of, in embryo, 55 
Shaving of patient, 45, 130, 137, 

165, 177, 228 
Sheets, arrangeme'nt of, 139, 140 
Shock of labor, 81, 257 

reaction from, 251 
Shoes for baby, 312 

for pregnancy, 105 
Shoulder presentation, 100, 240 

impacted, 239, 240 
Shower bath, 132 
Sight, disturbance of, 202 
Sims's position, 242, 243 
Simpson's forceps, 223 
Sitting up, 181 
Size of child, control of, 109 

of uterus, 36 
Skeleton of infant, 57 
Skin, increased activity of, 71 

of premature infant, 355 

streaking of, 67 
Skull, foetal, 59 
Slapping infant, 318, 320 
Sleep during pregnancy, 108 

for nursing mother, 363 

of infant, 294 
Sleeping with patient, 181 
Sling sheet, 219 
Sloane Maternity Milk Set, 384 

stocking, 122 
Smegma, 296 
Snap fastenings, 312, 405 
Snapping soles of feet, 319 
Snuffles, 212 
Soap for baby, 303 

green, 134, 170 
Social standing a factor in preg- 
nancy, 74 
Socks, 310, 312 
Sodium bromide, 184 
" Soft spot " on forehead, 60 
Solutions, antiseptic, 139, 140, 401 

for eyes, 290 




472 



INDEX. 



Souring of milk, 388 
Special nurse, 120 
Spermatozoa, within vagina, 44 
Spermatozoon, union of, with 

ovum, 48 
Spina bifida, 340 
Spinal cord, bulging of, 341 
Spine, fraction to, 320, 323 
Sponge baths, 137, 178 
Sponges, abdominal, 404 

cotton and gauze, 230 

loss of, 233, 404 

sterile, 177 

technic for, 404 
Spots before eyes, 197, 205 
Spraying of infant, 292 
Stages of labor, 76 
Stagnation of milk, 284 
Stanis from chemicals, 402 
Stair climbing, 107 
Starvation temperature, 184 
State laws on midwifery, 407 
Statistics concerning obstetrics, 20 
Steam sterilizer, 390 
Steelyards, 395 
Sterile soap, 23 
Sterility, 213, 276 
Sterilization, 22, 401 

for infusion, 270 

of bed, 128 

of catheter, 173 

of clothing, 122, 137 

of hands, 134, 402 

of instruments, 222 

of milk, 389 

of nursing bottles, 387 

of rubber bags, 224 

of rubber nipples, 387 

of supplies, 123, 124 

technic of, 401 
Stiffness from clot, 278 
Stimulation of patient, 259, 267 
Stocking, maternity, 122 
Stomach-tube, feeding by, 399 



Stools, curds in, 2>72> 
Straining during labor, 259 
Strangling, danger of, 158 
Streptococcus infection, 277 
Striae, abdominal, cause of, 68 

gravidarum, 67, 68 

in skin of breasts, 69 
Stricture, congenital, 311 
Study, excessive, 45 
Subinvolution, 81 
Sublamin, 401 

Suckling as cause of uterine con- 
tractions, 41, 113 

discomfort from, 283 

impossible, 344 

interference with, 279, 283 

position for, 366 

prevention of, 114 
Suffering, puerperal, 25 
Suffocation of infant, 345 
Sugar, fat-producing, 376 

in milk, 378, 381 

in urine, 73 
Suicide, tendency to, 278, 288 
Sunshine for baby, 299, 304 
Supervision of pregnancy, 26 
Supplies needed by nurse, 396 

renting of, 124 
Suppression of menstruation, 45 
Suppuration of breast, 283, 287, 

342 
Surgery in ectopic pregnancy, 208 
Surgical dressings, 124 
Suspended animation, 317 
Sutures of cranium, 58, 59, 60 

perineal, 171, 176 
Swabbing the mouth, 364 
Swallowing pins, 305 
Sylvester's method, 327 
Symphyseotomy, 31, 234, 236 
Symphysis pubis, 28, 30, 33 
Syncope, 192, 194, 253 
Syphilis as cause of abortion, 211 

transmission of, 212 



INDEX. 



473 



Syphilitic infection, 212, 213 
nipples, 287 

Table, dressmaker's, 247 

for dressing baby, 303, 309 

Tampico fibre brush, 134, 402 

Tamponing, 266, 268 

Tape for cord, 395 
fastenings, 305 

Tarnier basiotribe, 239 
forceps, 223 

Tarnier's incubator, 353 

Tarry discharge from vagina, 97 

T-binder, 132 

Tears, excessive secretion of, 193 

Technic, hand preparation, 401 

Teeth, care of, 108 

false, 141, 145, 203 

Temperature after labor, 81 
charts, 177, 394 
in puerperal fever, 275 
of incubator, 349, 351, 353 
of infant, 294, 306 
of nursery, 299 
of operating room, 233 
of premature baby, 355 
subnormal, 348, 349 

Tenesmus, rectal, 191 

Tennis, 106 

Terror of water, 309 

Terrors of nursery, 295 

Test meal, 400 

Tetanus, 344 

Teterelle, 359 

Thermometry, clinical, 177, 394 

Third stage of labor, yy, yg 

Thirst from hemorrhage, 205, 255 
of baby, 298, 359, 368 
relief of, 185 

Threatened miscarriage, 256 

Throat, mucus in, 317, 318, 319 

Thrombus, 271 

Time for labor, 75 

Tissue, injury of, 329 



Toilet of mother, 178 

screen, contents of, 316 
Tongue, biting of, 203 

bleeding from, 199 

cleansing of, '308 

traction, 320, 323, 326, 332 
Toothache, 108 
Top milk, 380, 382 
Towels, clean, 121, 123 
Toxaemia, eclamptic, no 

general, 187, 197, 198 

indicated by vomiting, 86, 187 

of liver, 203 
Traction on body during delivery, 

155 
Training of infant, 295, 306 
Transverse presentation, 99, 101, 

215 
Tray for care of breasts, 279 
Trendelenburg position, 261 
Treponema pallidum, 211 
Triplets, 65, 66 

Tub-bath for baby, 293, 302, 304 
for baby, temperature of, 

306, 308 
in pregnancy, 108 
Tubal pregnancy, 206, 208 
Tuberculosis in pregnancy, 211, 

213 
Tubes, removal of, 234 
Tucker-McLane forceps, 223 
Tumor, abdominal, 228 
of spina bifida, 341 
Turpentine enema, 137 
Twelve per cent, milk, 378, 380, 

384 
Twentieth century civilization, 27 
Twilight sleep 160 
Twin, decapitation of, 238 

pregnancies, 76, 190 
Twins, abdomen containing, 68 

causation of, 65 

delivery of, 157, 158 

locked, 157, 159, 238 



474 



INDEX. 



Twins, precautions concerning, 154 

umbilical cords of, 66 
Typhoid state, 184 
Tubercles of Montgomery, 69, 87 

Ulcer, syphilitic, 211, 212 
Ulceration of tumor, 341 
Umbilical cord, 53, 116 

compression of, 317 
cutting of, 65 
detachment of, 294 
prolapse of, 259 
shortness of, 258 
tying of, 66 

hemorrhage, 326, 329 

hernia, 342 

vegetations, 343 
Umbilicus, 53. See also Navel 

infection of, 340 

protrusion of, 68, 69 
Unavoidable hemorrhage, 253, 254 
Unconscious patient, 204 
Under-feeding, 180 
Uniforms for nurse, 394 
Uraemia, 194 

convulsions of, 199 
Urea, excretion of, 198 
Urethra, 35 
Uric acid deposit, 296 
Urinary colic, 346 
Urination in new-born, 298 

stimulation of, 172 
Urine, examination of, 113, 118, 
196, 198, 200, 202 

in hysteria, 201 

of eclampsia 200 

of pregnancy, 73 

retention of, 83 

voiding of, 172 
Uterine dilator, 247, 248 

inertia, 222, 264 
Uterus as a nest, 117 

bleeding from, 154 

bleeding into, 254 



Uterus, cancer of, 412 

contraction of, 41, 81, 83, 85, 

242 
enlargement of, 89 
infection of, 21 
inversion of, 154 
mucous membrane of, 49 
openings of, 39 
packing of, 252 
palpation of, 101 
pregnant, 36, 67 
pressure of, upon lungs, 70 
relaxed, 81, 162 
removal of, 226, 228, 234 
rupture of, 217, 257 
sinking of, 76 
tilting of, 38, 86 
virgin state of, 35, 81 

Vagina, 34 

aseptic state of, 35 
irrigation of, 177 

Vagina of infant, bloody discharge 
from, 297 
packing of, 243, 252 
secretion of, 21, 69, 137 
violet hue of, 69, 85, 89 

Vaginal discharge after meno- 
pause, 412 

meconium in, 156 
douche, 35, 176, 194 
examination, 139, 403 
mucous membrane, 89 
operation, 219 
secretion a lubricant, 69 
walls, return of, to normal, 82 

Vaginitis, 297 

Varicose veins, 104, 189, 191 

Vegetations, umbilical, 343 

Veins, clot in, 277 

Ventilation, 180 

of incubator, 351, 353 

Vernix caseosa, 58, 292 



INDEX. 



475 



Version, external, 214, 215 
indications for, 222, 243 
operation of, 101, 209 
internal, 214, 217 

Vertex presentation, 91, 93 

Vesical tenesmus, 191 

Virgin state of uterus, 81 

Vision, double, 197 

Visiting nursing, 406, 408 

Visitors, 80, 180 

to incubator baby, 354 

Vital resources, conservation of, 

19 
Vomiting due to ether, 146 

during labor, yy, 78 

morning, 85, 86, 183 

of albuminuria, 197 

of infants, 367 

of pregnancy, 70, 86 

pernicious, 186 

relieved by bromide, 184 

uncontrollable, 186 
Vulva, 34 

cleansing of, 132, 171, 251, 403 

infection of, 138 

pads, 23, 133, 137, 170 

Waist, pressure about, 103 
Waiting, time lost by, 119 
Walcher posture, 218, 220 
Walking during pregnancy, 105, 

106 
Wansbrough's shield, 282, 283 
Wash-basin, double, 302, 309 
Washing of baby's clothing, 316 
Washrags, 303, 309 



Water, boiled, for baby, 298, 359, 
368 

for colic, 346 
intake of, 112 
sterilization of, 401 
Water-closet, non-use of, during 

labor, 132, 1 37 
Weather and out-door exercise, 

105 
Weight chart, 309 

of baby, 309, 348, 394 
doubled, 367 
loss of, 368 
new-born, 297 
normal increase in, 298, 

364 

Wet-nurse, milk of, 360 
mortality of, 374 
selection of, 374, 375 

Wharton's jelly, 55 

Whiskey by hypodermic, 323 

" Whites," 194 

Winckel's disease, 340 

Windows, protection of, 250 

Wipes, burning of, 170, 213, 335 

"Wobbly" gait, y3 
position of head, 96 

Womb, 35. See Uterus. 

Wool flannel for baby, 311 

Woolen underwear in pregnancy, 
103 

Yellow crust on head, 311 
Yellowness of skin, 340 

Zone, temperate, puberty in, 45 
Zoolak, 397 



